We Deliver Quality of Life

Application for Service

Client Information





County:



Birth date:

Race:

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

What Program are you applying for?

Reason for needing assistance:

I am homebound

I am unable to shop or cook for myself

Have you or your spouse ever served in the military?

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

When would you like to begin service?

As soon as possible

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 itemize your income and 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.

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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