Please complete and submit this form for yourself. Once you have successfully submitted your own form, complete and submit a new form for your spouse or partner.

Based on this brief assessment, home-delivered meals may not the best LifeCare Alliance Nutrition Service for your situation. However, we have many other services that might be appropriate. A representative of the LifeCare Alliance will be calling to discuss more.

Based on this brief assessment it is likely that you or your loved one would benefit from LifeCare Alliance’s home-delivered meals program.

Once you have completed this home-delivered meals questionnaire, you will be taken back to the LifeCare Alliance general referral form.

What type of meal delivery is best for you? (select your preference – you must be home at time of delivery. Meals cannot be left at the door or with a neighbor.)

• Daily delivery (deliveries are hot or cold and are made typically between 10:00 and 2:00)

• Weekly delivery (deliveries are frozen and only come once a week on a set day between 8:00 and 4:00)

It is possible you will qualify to receive up to 14 meals per week with your delivery. One of the LifeCare Alliance case managers will make this determination based on your unique situation.

LifeCare Alliance’s home-delivered meals are provided at no cost to its customers. However, we appreciate and accept contributions to the program. Even .10 per meal (approximately $2.50 per month) can help LifeCare Alliance sustain the service for all in need. If you are interested in contributing towards the cost of your meal, please indicate the amount per meal that would be comfortable for you. LifeCare Alliance will send you monthly reminder letters to indicate how much you have pledged to contribute towards your meals. Contributing the amount in the “pledge” letter is not mandatory to continue to receive the service. Additionally, your pledged amount per meal can be lowered, raised, or discontinued at any time. As mentioned above, there is no cost for the meals, and service will not be denied if you are unable to contribute towards the program. We are honored to serve our customers regardless!

Based on this brief assessment, homemaking services may not be the best service for your situation. However, we have many other services that might be appropriate. A representative of the LifeCare Alliance will be calling to discuss more.

Based on this brief assessment, homemaking services may not be the best service for your situation. However, we have many other services that might be appropriate. A representative of the LifeCare Alliance will be calling to discuss more.

Based on this brief assessment, homemaking services may not be the best service for your situation. However, we have many other services that might be appropriate. A representative of the LifeCare Alliance will be calling to discuss more.

Based on this brief assessment it is likely that you or your loved one would benefit from LifeCare Alliance’s Help at Home program.

LifeCare Alliance’s homemaking program is provided at no cost to its customers. However, we appreciate and accept contributions to the program. Even $1 per hour of service can help LifeCare Alliance sustain the service for all in need. If you are interested in contributing towards the cost of your homemaking hours, please indicate the amount per hour that would be comfortable for you. LifeCare Alliance will send you monthly reminder letters to indicate how much you have pledged to contribute towards your homemaking service. Contributing the amount in the “pledge” letter is not mandatory to continue to receive the service. Additionally, your pledged amount per hour of homemaking can be lowered, raised, or discontinued at any time. As mentioned above, there is no cost for the homemaking service, and service will not be denied if you are unable to contribute towards the program. We are honored to serve our customers regardless!