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VirtuVisit: Participant Intake Form

Thank you for your interest in participating in the VirtuVisit Program. We look forward to partnering you with a tech-buddy volunteer who will assist you in connecting with friends and family members via a video call. As a participant in this program you will be assigned to a volunteer who will support you in setting up a tech device, answer questions and guide you through your first several video calls. Your tech-buddy will support you through the program until you are comfortable making video calls on your own.

We need some general information to ensure you are eligible for the program. 
This question requires a valid number format.
This question requires a valid date format of MM/DD/YYYY.
6. Do you have a family member that we can work with to help you get set up on your device? 
7. Can our volunteers call you? 
7. Can our volunteers text you? 
7. Indicate how often each of these statements are descriptive of how you feel during COVID-19. Check all that apply.
Space Cell I often feel this wayI sometimes feel this wayI rarely feel this wayI never feel this way
I feel isolated from others
I no longer am able to visit with family and friends
8. Access to Wi-Fi and Computer Knowledge

Do you have access to the internet (Wi-Fi) in your residence?
*This question is required.
9. Do you know the internet (Wi-Fi) password?
9. Do you have a Facebook account? *This question is required.
10. Do you have Facebook Messenger? *This question is required.
11. Do you have a WhatsApp account? *This question is required.
12. Can we create a Facebook account for you? 

Having a Facebook account allows you to use more devices and better maintain your contacts for making video calls to friends and family.

12. Do you have a smartphone? (e.g. iPhone, Android)
13. Please tell us how comfortable you are using technology/computers. This will help us tailor your training. 
Space Cell Very ComfortableComfortableNot ComfortableVery Uncomfortable
Using the internet and browsing websites
Using technology to connect with family and friends
14. Would you like to be able to use Zoom?