BetterTogether Seniors™ Questionnaire

Please fill out this questionnaire to help us match you with a compatible companion.

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Section 1 of 13

SECTION 1 - Basic Information

1. Full Name *

2. Preferred Name / Nickname

3. Age

4. Gender

WomanManPrefer not to sayPrefer to self-describe:

5. Your Address (for proximity matching)

6. Preferred Contact Method

Phone callTextEmailAny is fine

7. Emergency Contact Name + Phone (optional but recommended)