Life Story Club Member Profile
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Please fill out this Member Profile form so we can place you into a Club that is right for you! New participants will receive a welcome call from our Client Experience Manager within 48 hours.

Please note, Clubs are best suited for older adults 60+ and are offered in English, Spanish, Mandarin and Cantonese.

Life Story Club is not a substitute for therapy. Participation in Life Story Club requires individuals to listen to the stories shared by other club members. LSC may be ill-suited for individuals with the following:


- Moderate/severe dementia or Alzheimer's (mild cognitive impairment ok)
- Severe depression, anxiety, or suicidal ideation
- Emotional dysregulation
WELCOME!
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Participant First Name: *
Participant Last Name: *
Participant Preferred Pronouns
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Participant Contact Info
Participant Phone Number: *
Participant Address
Street *
City *
State *
Zipcode *
Participant Date of Birth: *
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Participant Language Preference
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What aspects of the Life Story Club program appeal to you? (select all that apply)
I am eligible for Medicaid
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Which of these topics interest you? Select all that apply!
We can't wait to meet you! Please describe yourself in a few sentences?
If you're interested in capturing/saving a story, is there a particular story you're hoping to save? Who is it for?
How did you hear about Life Story Club?
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