First Name

Last Name

Birth Date

Gender (Identifies as)

male
female

Home Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Home Phone

Cell Phone

Email

Prefer call in

a.m.
p.m.

Specific Directions to Home

Occupation/Previous Occupation

Primary Language

Number of years living in Sioux Falls

Do you live alone?

yes
no

If no, who do you live with (name/relationship)?

Do you smoke?

yes
no

Are there any smokers in your home?

yes
no

Do you have a pet?

yes
no

Name and type of pet

Have you ever been convicted of a drug charge?

yes
no

If so, charge and year it occurred

Have you ever been convicted of a criminal offense?

yes
no

If so, charge and year it occurred

Have you ever been convicted of abuse, neglect, or assault?

yes
no

If so, charge and year it occurred

How is your hearing?

excellent
good
poor
need to use hearing aids
deaf

How is your vision?

excellent
good
poor
need/wear glasses
blind

How is your mobility?

excellent
good
poor
can walk alone
walk with assistance/walker
wheelchair

Any concerns?

Preferences for Match

female
male
couple
family with older children
family with younger children
small group
no preference

How did you hear about LSS Better Together? Check as many as apply and describe below

Please provide any additional referral details

Emergency contact name

Relationship

Phone

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

I would like to meet:

once per week
every other week
once per month
twice per month
other

Please define the other times you would like to meet:

I am interested in participating in monthly events organized by LSS:

yes
no
on occasion
not sure

Please list any other information about yourself you feel would be helpful in matching you. This can include any special hobbies, talents, or interests.

Please describe a few things you would like to do when participating in this program.

Why are you interested in participating in this program?

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Any issues of concern to note (family history, physical/mental health issues, health conditions)?

What other community programs are you involved in or what community services do you receive (Meals on Wheels, Service Club, Church, Social Worker, Senior Companion, etc)?

Better Together Neighbor

We're glad you're here!

Referral Information

Matching Information