ElliQ Sign Up Form

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ElliQ Sign Up Form

ElliQ is a proactive, voice-operated care companion robot designed to empower independence and support seniors in taking control of their social, mental and physical wellbeing

ElliQ is best suited for older adults who spend most of their day at home but would enjoy some company throughout the day, as well as, older adults that feel they can use the extra companionship and the right encouragement to be more active throughout their day.

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メールアドレス *

First Name *

Last Name *

Gender *

Female

Male

Prefer not to say

Date of Birth *

YYYY

Ethnicity? *

Hispanic

Non Hispanic

Race? *

Address *

City *

Zip Code *

Mobile Phone Number *

Secondary Phone Number

English Speaking? *

Yes

Primary Language *

Do you have Internet Access? *

Yes

Do you know your WiFi name and Password? *

Yes

How did you hear about this program? *

Disabled? *

Yes

Do you have any of the following impairments? (Check all that apply) *

Total Loss of Hearing

Total Loss of Vision

Severe Speech Disorders

None

必須

Have you ever been diagnosed with dementia or Alzheimer's Disease? *

Yes

Are you currently receiving services through the Medicaid Long-Term Managed Care Program?

Yes

Do you live alone or with others? *

Alone

With others

If you live alone, how much time do you spend by yourself?

100% of the time

More than 50% of the time

Less than 50% of the time

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Emergency Contact Name *

Relationship to Member *

Emergency Contact Phone *

Name of Staff Person Filling out Form
*

N/A

その他:

Notes

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