Exhale – Information Request Form

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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)*

First Last

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Age

Gender

Our Services:

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

1) 4 Hour Respite Day - Fun and engaging activities for older adults age 55+ offered monthly at three locations in Buffalo.

2) Case Management - Support services to ensure you have the help you need.

3) Transportation to Exhale program activities, etc.

4) Caregiver Clubhouse - For family, friends and loved ones who care for older adults age 55+ and need a little support too.

Your Information:

Name (of person making referral)*

First Last

Phone*

Email*

Relationship to older adult age 55+

If you are the caregiver (someone who takes care of or looks after a senior/loved one), are you feeling overwhelmed?

Would you like to be contacted with information for caregiver support groups?

This field is for validation purposes and should be left unchanged.