Always In Touch Application

Client Name*

First NameLast Name

Referred by*

Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Client Phone Number*

Area CodePhone Number

Client E-mail

Client Birth Date*

MonthDayYear

Gender*

MaleFemale

Marital Status

Ethnicity

Primary Language*

Living Arrangement

Do you have Philips Lifeline

YesNo

If you have Lifeline, through which agency

Primary Care Physician

First NameLast Name

Primary Care Physician Phone Number

Area CodePhone Number

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

Emergency Contact E-mail

Relationship to Client*

Click this box if you would like to be notified by e-mail if the client does not answer the phone in 10 rings or if information shared on the call with the Always In Touch representative might be considered life threatening in nature.

Secondary Emergency Contact Name

Secondary Emergency Contact Phone Number

Area CodePhone Number

Secondary Emergency Contact E-mail

Calls may be made between 8am and 2pm Pacific time. Approximate call time will be arranged with AIT Representative. Excludes weekends and holidays. If the AIT Representative is not able to reach you by phone, Always in Touch will contact the emergency contacts if listed on this application.

Please select the type of call*

Quick Daily Check-In Call: Up to 5 MinutesWeekly Socialization Call: 10 to 15 Minutes

Preferred Time to call*

Please select possible questions that you would like your Always In Touch representative to ask on their call?

How are you feeling today?How is your morning going?What's new and exciting?How is your family? When did you speak to them last?Did you eat something good for breakfast/lunch/dinner yesterday? What was it?Are you going to get out today? Are you keeping dry/cool/warm enough?Will you be able to get exercise today?What are you going to do for fun today?

Is there anything else that you would like to share with your Always In Touch representative (likes, dislikes, hobbies, family information, pets, etc.)?

In requesting services from the Always in Touch program, I understand that a confidential file will be kept including this agreement and other written notes regarding my history, health and general condition. This record is confidential and will be seen only by the management team and designated employees. I agree that this information will not be released except to people you have designated on this agreement and to first responders if our employees need to call them as described in the Program description, and I consent to such disclosures. These services are voluntary and I may cancel at any time. There is no cost for the services that the Always In Touch program provides.

Always Best Care Senior Services, its franchisor, ABCSP LLC. its franchisees, and Always in Touch representatives are not offering to act as or to replace medical alert organizations, care givers or family members; nor are they offering any medical or health care services of any kind and they are not liable for any illness, death or injury which may occur to users of the Always in Touch service.

Always in Touch is a free program created by Always Best Care Senior Services which offers peace of mind to individuals, family and friends, and provides daily socialization and telephone reassurance for seniors so that they are “not alone.” Always in Touch is staffed by caring individuals who place calls to participants according to a schedule which has been agreed upon by the senior or his/her family.

If a senior does not answer a call, Always in Touch will follow the protocol the senior or his/her family has prescribed and call designated family members or friends.

Always in Touch is intended to serve seniors or disabled adults who are homebound, isolated, living alone, and recuperating from an illness or in need of daily contact on either a temporary or permanent basis.

How the Program Works
Always in Touch will do their best to place calls at an agreed upon time frame. They are instructed to allow the phone to ring up to 10 times, and if there is no answer they will try again later in the day if time permits. If there is still no answer, they will try to reach emergency contacts* designated in the Agreement if there are agreements made between the caller and the client. However, due to nature of the program, we cannot guarantee that our callers will follow the standard protocols every day. Always Best Care reserves the right to cancel this agreement at any time.

In an effort to meet the needs of Always in Touch participants, it is sometimes necessary to contact and share information with other community services and agencies. This may include the disclosure of personal or confidential information. Sharing this information is intended to assist participants of the Always in Touch program.

I authorize the Always in Touch program to obtain and/or disclose confidential information to/from other community social services agencies.

Please use the box below to sign with your mouse, or finger if you are using a touchscreen.

Applicant or Legal Representative Signature*

Today's Date*

MonthDayYear

* We will not call the police department or other public agency unless we are on the phone with the senior and it’s an emergency. This program is not designed to replace medical care, personal care, home care or emergency response systems. If you require guaranteed responses, we recommend that you contract with a company such as a local Always Best Care Senior Services office, which provides paid, guaranteed services.

Always In Touch Application

Client Information

Emergency Contact Information

Telephone Reassurance Calls

Confidentiality Statement

Release of Information