Request for Volunteer Correspondent

Name

First

Last

District

DOB

EIS #

Guardianship

name & contact

Address

City

State/Province

Zip/Postal

Consumer

Phone Number *

Primary

Had A Correspondent before? *

Yes

Family Members Involved

Amount of Involvement

Please list name and phone number of person(s) interested in becoming correspondent

Is this referral the result of a planning meeting?

Yes

If yes, date meeting

Please attach a copy of the planning meeting report.

Maximum upload size: 2.1MB

If this referral did not result from a planning meeting, please explain why there is a need for a Correspondent.

Case Worker

Case Worker Full Name

Case Worker Email

Case Worker Phone

Case Worker Address

Street Address

Apartment/Building/Suite #

City

State/Province

Zip/Postal

Consumer Profile

The person who needs a Correspondent should complete this section of this form. If you need help, please ask your case manager, a staff person or a friend to assist you. This form will be used to match you with a Volunteer Correspondent who most closely fits what you want. The Volunteer Coordinator may meet with you to go over additional information that will help with the matching process.

What are some of the things you might like to do with a correspondent?

Are there some special skills that you would like your correspondent to have?

Use TTY or relay

Be able to learn special signs and words

Be able to help me use the restroom

Know or learn sign language

Be able to learn Facilitated Communication

Be able to help me eat if we go out

OtherOther

Do you have any special needs or any comments?

Signatures

Please sign your name below so that we will know that you want a Volunteer Correspondent. If someone helped you with this form, please ask that person to sign also.

Signature

Clear

Date

Assistant's Signature

Clear

Date

Assistant's RelationshIp to Consumer

If you are human, leave this field blank.