The Sourcewise Connections, Health, Aging & Technology program

Thank you for your interest in the Connections, Health, Aging & Technology (CHAT) Program ~ To help bridge the digital divide gap and address social isolation, Sourcewise is excited to offer the Connections, Health, Aging & Technology (CHAT) program. The program is free to eligible seniors and is provided in partnership with the California Department of Aging. Once eligibility is confirmed, program participants will receive an iPad to use for a limited time, coupled with training and general technical support. Devices are limited and available while supplies last. In you are interested in the program, please fill out this brief interest survey. If you qualify, someone from our team will contact you to set up a few research sessions before receiving your tablet. If you’re a caregiver and would like a tablet for someone you care for (older adult 60+ years), we recommend that you do the survey process together to confirm they consent to the program enrollment and requirements. You may contact our office at any time if you have questions or comments. You can email us at tech@mysourcewise.com or call at (669) 699-2245.

First Name *

Last Name *

Email

Phone Number *

Address *

City *

Select the Age Category That Applies: *

• 18-29
• 30-39
• 40-49
• 50-59
• 60-64
• 65-69
• 70-74
• 75-80
• 81-84
• 85+

Select your Income Level per Month: *Under $900$901 - $1,500$1,501 - $2,500$2,501 - $4,000$4,001 - $4,833Over $4,834Prefer not to respond

What language do you feel most comfortable speaking? *

• English
• Mandarin
• Vietnamese
• Spanish
• Other

Other Language

What other languages are you comfortable speaking?

• English
• Mandarin
• Vietnamese
• Spanish
• Other

Other Language

An informal caregiver is defined as someone taking care of an older adult or adult with a disability." Are you an informal caregiver? *YesNo

Do you live alone? *YesNo

Do you have wi-fi that is working? *YesNo

Please check any of these devices that you have in your home. More than one answer is accepted. *

• Desktop Computer
• Laptop Computer
• Tablet, e.g. iPad
• Smart Speaker, e.g. Alexa, Google Home, Siri
• Cell or mobile phone
• I have other technology that helps me with daily activities, (please specify)
• I have none of the above

Other Technology

On the scale of 1 to 10 below, how comfortable are you with learning new technology? 1 is very uncomfortable; 10 is very comfortable. Slide the circle.

Selected Value: 0

To participate in this program, you will need to participate in a total of 2 to 5 research sessions (up to 1 hour each) before and after receiving the device. This involves asking you questions over the phone. If at any time you are uncomfortable, you may decline to answer. Are you willing to participate in these sessions? *YesNoMaybe

Please check the services below where you would like to receive more information. *

• Information & Awareness (Find Older Adult Resources)
• Health Insurance Counseling (Medicare)
• Senior Employment Services
• Caregivers Network
• Meals on Wheels
• Care Management
• Public Authority Services
• Senior Farmer's Market
• Dignity at Home Fall Prevention
• Sourcewise Transit Services
• Other

Other Services

How did you find out about this CHAT program? *Postcard in MailEmail from SourcewiseCase ManagerFriend or Family MemberSocial Media

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