Referral Intake Form 





Client Information








Client Address




Client Questions


This includes Medicaid Waiver Meals

Independent living refers to residing in one’s own home or apartment, or in the home or apartment of a spouse, partner, relative, or friend; alternatively, it may include residing in a rented room, motel or hotel, or a homeless shelter.

Not Eligible
Thank you for your interest in our services. Based on your response, you are not eligible for the program at this time. Please call us if you have any questions. (603)-424-9967.
Demographics







Emergency Contact Information






Additional Questions
These questions help us understand the needs of our participant base. With this information, we are able to provide community resources and other referral information as applicable. Thank you for your continued support and participation in our program!
Activities of Daily Living
The following questions help us understand the kind of support you may need with daily activities. Please let us know how much assistance you typically require.
Do you need any assistance with the following:
Nutrition Screening
The following are true/false questions to complete the Nutritional Risk Screening. Please circle true or false based on how the statement applies to you, and add up the corresponding points to identify your nutrition risk score. If your total score is 6 or higher, we encourage you to follow up with your healthcare team for nutrition support
including education and nutrition counseling, if appropriate.
--- The numbers are associated with the score that should be tallied in accordance with the response. We are required to keep a record of your score if answered. ---
Thank you for your interest in our services. Based on your response, you are not eligible for the program at this time. Please call us if you have any questions. (603)-424-9967.

Contact Information