Exhale – Information Request Form

Exhale: Family Caregiver Initiative

The Gathering Place – Information Request Form

Exhale is a support services program for caregivers and their loved ones. Part of this program is The Gathering Place, which provides a 4-hour activity program offered monthly for seniors age 55+ at 3 locations in Buffalo: the BFNC Life Center, Schiller Park Senior Center, and Compeer.

Services are supported by Erie County Department of Senior Services, and Hearts & Hands.

The survey will take approximately 8 minutes to complete.

"*" indicates required fields

Person You Are Referring:

Name (of participant age 55+ being referred into program)*

Our Services:

Please select all the services you would like to learn more about (you can select more that one option):

Your Information:

Name (of person making referral)*
This field is for validation purposes and should be left unchanged.