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Care Circles Program™
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Home
Membership
How It Works
About
Contact
Care Circles Program™
Refer a Member
Because care grows stronger when it's shared.
Know a senior who would thrive with more connection, companionship, and joy? Fill out the referral form below to introduce them to
The Caretakers Club.
We'll take it from there—with kindness, warmth, and a personalized welcome.
The Caretakers Club:
Referral Form
Referrer Information
First & Last Name:
Organization Name:
Relationship with Client:
Family Member
Friend
Social Worker
Counselor/Therapist
Neighbor
Contact Phone:
Contact Email:
How Did You Hear About Us?
Google/Online Search
Social Media (Instagram/Facebook/Etc.)
Flyer/Printed Materials
Community Event/Fair
Outreach from The Caretakers Club
Other
Client Information
First & Last Name
Client Phone:
Client Email:
Preferred Method of Contact
Phone
Email
Client Date of Birth:
Reason for Referral: (check all that apply)
Social Isolation or loneliness
Seeking Meaningful conversation
Recently experienced a life transition (loss, move, retirement, etc.)
Needs uplifting engagement and light companionship
Other
If other, please specify.
Would this individual be open to connecting with another senior as part of our 'Friendline Initiative'?
Yes
No
Maybe
Additional information for companionship purposes (e.g. cultural background, language preferences, hobbies/interests, etc.)
I confirm I have the referred individual's consent to share their information and understand that The Caretakers Club may contact them.
Submit
