Request Service

Name
First Last
Phone
Email*
Current Address
Street Address Address Line 2 City State ZIP Code
Caregiver Name
Caregiver Phone
Family Support Name
Family Support Phone
Bikur Cholim of Hollywood offers support to those in the local Jewish community and surrounding areas facing needs, changes and challenges due to illness. Please review the following list of services we can provide, and mark the boxes for those you and / or your family would benefit from.
- Friendly visitors
- Phone Calls
- Meals (dietary needs will be discussed)
- Medical equipment (on-loan for a short-term)
- Someone to sing with
- Help with children in the home
- Someone to pray with and / or learn Judaic Studies with
- Take a walk outdoors
- Arts & Crafts activity (art; needlework; etc.)
- Read aloud Activity
- Playing games (cards, board games, etc.)
Best day & time for visits
Best day/ time of day for phone calls
Do you have a hearing deficit?*
- Yes
- No
Do you have a visual impairment?*
- Yes
- No
Are you ambulatory?
- Yes
- No
What is your primary language?
Please provide any other relevant information: