Intake – Connected Lives

Sevenza Global Services | Elderly Intake & Support Assessment

Sevenza Global Services (SGS)

Community impact • Digital inclusion • Senior support intake

Elderly Intake & Support Assessment

Elderly Intake & Support Needs Assessment

This form supports program planning, referrals, and community services. Provide only what you are comfortable sharing. If completing on behalf of an elder, identify yourself in the signature section.

Privacy Notice: Information is collected for intake, service planning, and follow-up regarding SGS programs. Data should be handled in accordance with applicable Canadian privacy law (e.g., PIPEDA) and SGS policies.

1. Participant Identification

Title

Preferred Name

First Name*

Last Name*

Date of Birth

Age

Gender (optional)

Primary Language

Do you require interpretation / language support?

Yes No

If yes, specify in notes below.

Interpretation Notes (if applicable)

2. Contact Information

Phone (Primary)*

Mobile or landline.

Email (if available)

Preferred Method of Contact

Best Time to Contact

Residential Address

3. Emergency & Care Contact

Emergency Contact Name

Relationship

Emergency Contact Phone

Is this person a caregiver or legal guardian?

Yes No

4. Living Situation & Current Supports

Current Living Arrangement

Lives alone Lives with spouse/partner Lives with family Assisted living Long-term care facility Other

Do you currently receive any supports?

Family caregiver Community support services Government assistance Faith-based/community organization None

Support Notes (optional)

5. Accessibility & Participation Needs (Non-Clinical)

This section is used only to plan accommodations. Do not provide medical diagnosis details.

Do you experience challenges with:

Mobility Vision Hearing Memory/cognition Speech None

Do you require accommodations to participate?

Yes No

Accommodation Details (if yes)

6. Technology & Digital Access

Devices available:

Smartphone Tablet Laptop/Desktop None

Internet access at home

Yes Limited No

Comfort level with technology

Beginner Intermediate Comfortable Prefer assistance

Would you like support with digital skills?

Yes No

Digital Support Topics (optional)

7. Social Engagement & Well-Being

How often do you interact socially (in person or virtual)?

Daily Weekly Monthly Rarely

Do you sometimes feel socially isolated or lonely?

Yes No Prefer not to say

Programs of interest (select all that apply)

Social connection activities Digital literacy & tech support Community information & referrals Transportation / access support Values-driven / faith-based support Other

Notes (optional)

8. Transportation & Access

Transport support is subject to availability. SGS may provide referrals or coordinate volunteer/community transport where applicable.

Do you need transportation assistance to attend appointments or SGS activities?

Yes No Sometimes

Preferred transport type

Volunteer ride Accessible vehicle required Public transit support Taxi/Rideshare support Family/Friend assistance Other

Mobility requirements (transport-related)

Wheelchair Walker Cane Assistance getting in/out None

Pickup Area / Neighbourhood (optional)

Typical Availability Window

Transport Notes

9. Provide Transportation (Volunteer / Community Support)

This section is for community members who want to offer rides. If you are an elder seeking transport, you can skip this section. SGS will contact you to confirm suitability and safeguarding steps.

Are you interested in volunteering to provide transportation?

Yes No

Volunteer Full Name

Volunteer Phone

Volunteer Email

Service Area

Vehicle / Availability (select all that apply)

I have a vehicle Weekdays Weekends Evenings Accessible assistance capable

Volunteer Notes

I understand SGS may request additional verification steps (e.g., identity/driver documentation, reference checks) where required for safeguarding.

10. Donate to Support the Cause

Donations support programs such as social connection, digital literacy assistance, and access support. No payment is collected through this form unless you integrate a payment provider.

Would you like to donate?

Yes No Maybe later

Intended Donation Amount (CAD)

Donation Frequency

Preferred method (for SGS to follow up)

Interac e-Transfer Credit card (via secure link) Cheque Bank transfer Other

SGS should provide official instructions via a secure channel after confirming donor details.

Donation Notes (optional)

11. Consent & Data Protection

Consent: You may withdraw consent at any time. SGS will use this information for intake, service planning, referrals (where applicable), and communications you authorize.

I consent to SGS collecting and using my personal information for program intake and service planning.* I consent to SGS contacting me about relevant programs, events, or support services. Where appropriate, I consent to SGS making referrals to partner/community services using only necessary information.

Privacy Questions / Restrictions (optional)

12. Signature & Declaration

Name (typed signature)*

Date*

If signed by caregiver/legal representative — Name

Representative Relationship

Representative Notes (optional)

Safeguarding: If urgent risk or emergency support is required, contact local emergency services immediately. This form is not monitored for emergency response.