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Application for Rocky's Agency on Aging Offerings

Please take the time to fill out this application completely. Incomplete forms may not be considered.

Please choose either a Companion Pet, Brainpath Disk, or both. If you would like both, please click your pet selection and the "Both" checkbox.

Companion Pets - Lifelike robotic pets demonstrated by National Studies to reduce distress and decrease loneliness in some elders, especially those with Alzheimer’s, dementia, and other cognitive disabilities. Due to these outcomes, robotic pets have also been shown to reduce burden of care for caregivers. Options include:

  • Cat
  • Kitten
  • Dog
  • Surprise Me

Brainpaths® Disks – A plastic disk with textures and mazes to stimulate the brain as fingertips indent into the textures. Fingertip-tracing textures fire and wire neurons to strengthen synapse connections necessary for long-term memory.

Please choose one or both:

Information about Applicant

First Name
Last Name
Address Line 1
Postal Code
Do you reside in a private home, assisted living, or a nursing home?
Do you have Alzheimer's, dementia, or another cognitive disability?
Do you have a disabling condition?

Information about Care Giver

Please provide us the contact information for your care givers below so that we may offer additional services to them and to you.  Care givers include family members, friends, and personal assistants.

First Name
Last Name
Address Line 1
Postal Code

COVID-19 intensifies social isolation among older Montanans. Rocky’s Area IV Agency on Aging will provide for free for qualified recipients, one mechanical companion pet and/or one Brainpaths Disk per client living in these counties: Broadwater, Gallatin, Jefferson, Lewis and Clark, Meagher, and Park. Funding for the offerings comes from the CARES Act and a donation by Blue Cross Blue Shield.

Printable Pet Companion Application

  • Rocky's Agency on Aging
    Rocky's Agency on Aging
  • MOW 2022
    MOW 2022
  • Head Start Logo
    Head Start Logo
  • Rocky Mountain Preschool logo
  • AmeriCorps Seniors
    AmeriCorps Seniors
  • Community Action Partnership logo
    Community Action Partnership logo

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