We Deliver Quality of Life

Application for Service

Client Information *

* Required fields





County:



Birth date: (XX/XX/XXXX)

Race:

Who should we contact regarding the application? (Please include name and phone number) *

Emergency Contact:



What Program are you applying for? *

Reason for needing assistance: *

I am homebound *

I am unable to shop or cook for myself *

Have you ever served in the military? *

Has your spouse ever served in the military? *

Health, mobility or dietary concerns we should be aware of:

Special dietary needs for delivered meals:

When would you like to begin service? (Please allow 3 business days)

Enter date: (XX/XX/XXXX)

Days Requested: *

Is this anticipated to be a temporary need following surgery, etc.?

Do you have a social worker or case manager assisting you from another agency?

Social Worker Info:



MONTHLY INCOME (Include all sources): *

Please note: This information helps us determine a manageable fee based on your income and expenses. Please be prepared to provide your MONTHLY income and MONTHLY expenses during the scheduled telephone intake. Although documentation is not required, it is important that you report both your full income and all your expenses accurately. Failure to report all sources of income may result in an inability to initiate services.

Please be prepared with the following information for our follow up call:

  • BGE
  • Personal Medical Care: In-Home aides, ensure/boost, depends etc.
  • Housing: Rent or Mortgage
  • Rx/prescriptions cost
  • Oil: heating (winter months)
  • Medical/Doctor: Co-pays
  • Telephone/Cable
  • Transportation
  • Taxes: Property, Outstanding IRS (Please specify)
  • Water
  • Insurance: Medical (out of pocket), Renters, Life or Homeowners (Please specify)

Name and phone number of Person Completing application:


Thank you for submitting your application. Someone from our office will contact you within 3 business days to schedule your telephone intake.

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