Secondary Contact Information
Please provide contact information of a family member, friend, or caregiver.
Answers remain confidential and are not used to determine service eligibility. This information is used anonymously and demonstrates that we serve a diverse audience as required by authorized funders, like the United Way.
I have electronically signed on the space below or have personally requested this service and authorized that this application be signed on my behalf. I confirm that I meet the eligibility requirement to qualify for MindsEye’s service. If loaned a radio or Echo Dot, which is the property of MindsEye, I will return said device when I no longer need the service.