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Referral Instructions

Referral Instructions Please read all Referral Instructions to ensure correct completion and submission of a Referral . All sections that apply to the Referral illness must be completed concisely and clearly. All supporting documents that are required for the Referral diagnosis must be submitted before service can begin. Eligibility Criteria: All referrals must have a qualifying illness or be receiving hospice care; a compromised nutritional status AND require assistance with at least one activity of daily living. Referral Illness Compromised Nutritional Activity of Daily Living HIV/AIDS Status Cancer (active treatment) Chewing Difficulty Ambulation Stage 5 Renal Disease Swallowing Difficulty Bathing Congestive Heart Failure Diarrhea (Persistent and Decision Making COPD lasting more than one Grocery Shopping Multiple Sclerosis (RRPS, month) homemaking SPMS, or PPMS) Nausea (lasting longer Meal Preparation Amyotrophic Lateral than 2 weeks) Transferring Sclerosis/Lou Gehrig's Vomiting (lasting more Disease (ALS) Middle or than 2 weeks).

Homemaking Meal Preparation Transferring Completed Forms: Mail: Client Services Fax: 202-635-4261 Questions: Email: 219 Riggs Rd NE Attn: Food & Friends Please call intake@foodandfriends.org Washington, DC 20011 Client Services 202 -269 6820. 2 Revised 6/2021 Client Intake Form ...

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