Nutrition and Aging Division Intake

Intake Form
Name of person requesting services:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Today*

MonthDayYear
Date
AGE
Our meals and transportation services are for adults aged 60 and older. Please check the birth date you have entered. If you are under age 60, please call our Access line at 858-637-3210 for assistance with finding an alternative provider.
Home Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Get Address Value
Is your mailing address the same as your home address?*

YesNo
Do you reside in a rural area?*

Decline to stateYesNo
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Zip Code
Home Phone*
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
Email
example@example.com

What services are you interested in receiving?*

Home Delivered MealsTransportation
Your home zip code is not in our service area for On The Go transportation services. Please call our Access Team at 858-637-3210 for assistance in finding an alternative transportation provider.
Your home zip code is not in our service area for Home Delivered Meals. Please call our Access Team at 858-637-3210 for assistance in finding an alternative meals provider.
Home Delivered Meals
To help us determine what meal delivery program will best serve your needs, please answer the following:*

Are you homebound due to an illness, disability, or isolation?Are you a spouse of a person who is homebound?Are you an individual with a disability who resides with a homebound meal recipient?Are you otherwise isolated?
Please describe your reason for isolation*
In the last 6 months, have you received meals from another San Diego County AIS provider?*

YesNo
Have you notified the other provider that you no longer wish to receive meals and are enrolling with another provider?

YesNo, and I will
Household Information
How many people, including yourself, live in your household?*

1234Other
What is your marital status?

Decline to stateSingleMarriedDomestic PartnerSeparatedDivorcedWidowed
Our programs serve households of all faiths and backgrounds. We'd like to ask if your household identifies as Jewish?

YesNo
Household Notes:
What is your approximate household income?

income* per
month
year
Decline to State*
Have you ever served in the United States military?*

YesNoDecline to state
Are you the spouse, legal partner, parent, or child of a person who is serving in or who has served in the United States military?*

YesNoDecline to state
If you identify as being military affiliated, check below if this statement is true: “I consent to this agency (JFS) and the California Department of Aging transmitting my name, email address, mailing address, and mobile telephone number to the Department of Veterans Affairs only for the purpose of receiving additional information on veterans benefits for which I may be eligible. I understand that this consent is valid for 12 months.”*

YesNo
Contact the California Department of Veterans Affairs (CalVet) to determine eligibility for services and supports at www.calvet.ca.gov or 1-800-952-5626.
Are you currently receiving SNAP benefits, also known as CalFresh?*

YesNo
Our CalFresh Enrollment Assistance Team can help with submitting a new application and with making sure you are receiving the maximum benefit. Would you like someone from our team to contact you about CalFresh?*

YesNo
Personal Demographic Information
What is your gender?*

Decline to StateFemaleMaleTransgender Female to MaleTransgender Male to FemaleGenderqueer/Gender Non-binaryNot Listed, select to specify
What was your sex at birth?*

Decline to StateFemaleMale
How do you describe your sexual orientation or sexual identity?*

Decline to StateStraight/HeterosexualBisexualGay/LesbianQuestioning/UnsureNot listed, select to specify
Ethnicity*

Decline to StateHispanicNon-hispanic
Race (check all that apply)*

Decline to StateWhiteBlackAmerican Indian/Alaska NativeAsian IndianCambodianChineseFilipinoJapaneseKoreanLaotianVietnameseRace not listed (please enter)
Language*

English SpeakingNon-English, select belowNeed interpreter
Non-English Language

American Sign LanguageArabicArmenianBurmeseCreoleChaldeanChineseCantoneseCambodianDariFrenchFarsiGermanHebrewHmongIlocanoItalianJapaneseKarenKoreanKinyarwandaKinyamulengeLaoMandarinMienPashtoPolishPortugeseRussian/UkrainianSamoanSpanishTagalogThaiTurkishVietnameseYiddishOther
Emergency Contact
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Activities of Daily Living

Please rate your ability to complete each of the following activities. If you require no assistance to complete the activity, please select 1 - independent ; if you are fully dependent on a caregiver or other person to complete the activity, please select 5 - dependent.

Please enter any notes from ADLs and IADLs
Nutritional Assessment:

Select all below that apply
Nutritional Assessment: (select if yes)*

Decline to State / None of theseI have an illness or condition that made me change the kind and/or amount of food I eat.I eat fewer than 2 meals per day.I eat few fruits or vegetables or milk products.I have 3 or more drinks of beer, liquor or wine almost every day.I have tooth or mouth problems that make it hard for me to eat.I don’t always have enough money to buy the food I need.I eat alone most of the time.I take 3 or more different prescribed or over–the-counter drugs a day.Without wanting to, I have lost or gained 10 pounds in the past 6 months?I am not always physically able to shop, cook, and/or feed myself.
Total Score
Do you have any dietary restrictions?*

YesNo
Please be aware that our food may contain or come in contact with common allergens, such as dairy, eggs, wheat, soybeans, tree nuts, peanuts, or fish. While we take steps to safely handle the foods that contain potential allergens, please be advised that cross contamination may occur. Any food allergy concerns should be directed to Alana Olson, RD before enrolling in the program.
If yes, please describe:
Do you have a working refrigerator?*

YesNo
Do you have a working microwave?*

YesNo
Do you have any pets?*

YesNo
If yes, please describe number and type:
Please make sure pets will be restrained during the delivery time.
Do you have health insurance?*

YesNo
To learn more about Health Insurance coverage, please call Covered California at 800-300-1506 or visit https://www.coveredca.com/
On the Go Transportation
On the Go provides curb-to-curb transportation service. Are you able to meet our driver at the curb of your pick up location(s)?*

YesNo
JFS staff may need to reach you while using this service and away from home. Do you have a mobile phone?*

YesNo
Mobile phone
Please enter a valid phone number.
Do you use a mobility device such as a wheelchair, walker, or cane?*

YesNo
Please enter details about the mobility device:
Please provide any specific directions or details we should know about your home to help us get to you (gate code, house color, location of house number, etc)
Initial Ride Request
Would you like to provide information about your first ride request?

YesNot at this time
Please provide the following details about your first ride request and the coordinator for your region will contact you to confirm the details of your first ride and answer any questions about the program.
Date of Reservation Request
Pick up Time
Return Time
**Please allow a minimum of 1 hour for routine medical appointments**
Destination (or facility) Name
Destination Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number of Destination ( ex. doctor's office )
Please enter a valid phone number.
Waiting List Priority Score
Name of person completing form:
Referrals Made:

Nutrition education/coaching for at risk clientTransportationCase ManagementOther
Additional Notes:
Referral emails

Home Delivered MealsTransportationCalFreshCAC
Jotform
Should be Empty:

	1 Independent	2 Verbal Assistance	3 Some Human Help	4 Lots of Human Help	5 Dependent	6 Decline to State
Feeding
Dressing
Bathing
Transferring In/Out of Chair
Walking
Toileting

	1 Independent	2 Verbal Assistance	3 Some Human Help	4 Lots of Human Help	5 Dependent	6 Decline to State
Meal Preparation
Shopping
Manage Medication
Money Management
Telephone
Transportation
Light Housework
Heavy Housework

Intake Form

Our meals and transportation services are for adults aged 60 and older. Please check the birth date you have entered. If you are under age 60, please call our Access line at 858-637-3210 for assistance with finding an alternative provider.

Your home zip code is not in our service area for On The Go transportation services. Please call our Access Team at 858-637-3210 for assistance in finding an alternative transportation provider.

Your home zip code is not in our service area for Home Delivered Meals. Please call our Access Team at 858-637-3210 for assistance in finding an alternative meals provider.

Home Delivered Meals

Household Information

Personal Demographic Information

Emergency Contact

Activities of Daily Living

Nutritional Assessment:

On the Go Transportation

Initial Ride Request

Please provide the following details about your first ride request and the coordinator for your region will contact you to confirm the details of your first ride and answer any questions about the program.

**Please allow a minimum of 1 hour for routine medical appointments**

Please allow a minimum of 1 hour for routine medical appointments