*PLEASE NOTE: THIS REFERRAL FORM MUST BE COMPLETED IN ITS ENTIRETY IN ORDER FOR THE PARTICIPANT TO BE CONSIDERED FOR THE PROGRAM*
Referring Agency Point of Contact
Please complete the information below for the participant:
(The participant is the individual for whom the device is being requested)
General Information: Potential participants must have a genuine interest in using the device to maintain and/or increase their
options for communication and social interactions with others. The referring provider must assess the potential participant using the UCLA-3 Item Loneliness Scale.
The three questions below measure three dimensions of loneliness: relational connectedness, social connectedness and self–perceived isolation.
The responses to the questions will be scored as follows:
|Some of the Time
The score for each individual question is tallied together to give you a possible range of scores from 3 to 9.
General Screening Questionaire
Hardware, Software and Support
This program is funded by the Department of Health and Human Services, Administration for Community Living, Grant No. 90NWC30043-01-00