Apply Now

Project Angel Heart prepares and delivers medically tailored meals, free of charge, for people living with life threatening illness. To be eligible, individuals must be diagnosed with a life-threatening illness AND have side effects from their medical condition/treatment and/or a mental illness or cognitive disability that restricts them from obtaining or preparing nutritious meals.

To apply for services, the Health Care Provider Authorization and Confirmation & Client Release MUST be completed and signed by the client and their health care provider or social worker.

Applicant Information
First Name
Last Name
Middle Initial
Date of Birth
MM slash DD slash YYYY
Delivery Address
Address City State ZIP / Postal Code
County
Mailing Address (if different from delivery address)
Address City State ZIP / Postal Code
Email
Height
- cm
- in
Weight
- lbs
- kg
Gender
Race/Ethnicity
Preferred Language for Communication
Does the Primary Contact Speak English
- Yes
- No
- Limited
Primary Contact Name/Relationship
Primary Contact Phone Number*
Emergency Contact (Only list those who are aware of applicant's medical diagnosis)
Emergency Contact Phone Number
Household Information
(Income does not determine eligibility for services, it is collected for grant purposes only)
Monthly Household Income
Source of Income
Number of people in the household
Is the applicant a caregiver for children under 18 or another adult in the household?
- Yes
- No
Does the applicant have additional support or a caregiver when needed?
- Yes
- No
Has the applicant experienced food insecurity in the last six months?
- Yes
- No
Additional comments
Additional comments/concerns we should be aware of
Primary Diagnosis
Complete this section or securely email an active diagnosis list to refer@projectangelheart.org
Primary Diagnosis*
- HIV/AIDS
- Cancer
- ESRD
- Chronic Kidney Disease (please select a stage below)
- COPD
- Cystic Fibrosis
- Other Lung Disease (enter below)
- Heart Failure
- Other Heart Disease
- Multiple Sclerosis (MS)
- Protein Calorie Malnutrition / Failure to Thrive
- ALS
- Huntington’s
- Parkinson’s
- Lupus
- RA
- High-Risk Pregnancy
- Gestational Diabetes
- Pre-Eclampsia
- Dementia
- Other
Cancer Type
Is the Cancer Diagnosis Active?
- Yes
- No
Current Cancer Treatment:
- Chemo
- Surgery
- Radiation
- Immunotherapy
- No current treatment
Reason for no current treatment…(hospice, treatment plan pending, applicant choice, treatment on hold)
Chronic Kidney Disease stage (Check one):
- 1
- 2
- 3
- 4
- 5
- N/A
Other Lung Disease:

Please enter your information below.
Other Heart Disease:

Please enter your information below.
Due Date
Type of Dementia
Other
Other Concerns/Diagnosis
Other Concerns/Diagnosis
- Diabetes Type 1
- Diabetes Type 2
- Ambulation Device
- Unintentional Weight Loss
- Mental Illness/Cognitive Deficits/Substance Abuse
- Partially Blind
- Legally Blind
- Deaf
- Hard of Hearing
Does the applicant have two or more limitations around ADL's or IADL's?
- Yes
- No
Oxygen
- 24/7
- As Needed
How many liters of oxygen?
Describe:
Please include how many lbs, when, and over how long did the weight loss occur?
Describe Mental Illness/Cognitive Deficits/Substance Abuse
Describe other conditions:
Diet
Please indicate the requested diet and any other dietary needs due to allergies, side effects from treatment, religious beliefs, etc. All of our diets are heart healthy. Please note: we cannot accommodate all diet requests.
- Renal
- Heart Healthy
- Gluten-Friendly
- Vegetarian
- Difficulty Chewing/Swallowing
- Low Vit K/GI-Friendly
- Diabetic
- Dairy Free
- Unseasoned
- Food Allergies
Describe Food Allergies
Nutrition education and counseling
Would you like our Registered Dietitian to contact you?
- Yes
- No
If you have specific questions, please list those here:
Health Care Provider Consent
Referrer's Rating – How critical is the need for services considering nutritional need and access to resources. One being the lowest and 10 being the highest need:
The medical professional’s signature below:

1. Verifies the applicant named in this application is their patient

2. Confirms that all stated health information on this application is true and accurate
Referring Health Care Provider
(doctor, nurse, licensed clinical social worker, dietitian, etc.)
Name
Title
Phone
Fax
Email
Agency, clinic, hospital, or practice
Signature
Date
MM slash DD slash YYYY
Project Angel Heart Application for Services Consent
The following confirmation/applicant’s consent must be completed, signed, and submitted with the application. By signing this document, I (named below), voluntarily consent for the exchange of my health information between Project Angel Heart and my health care provider, social worker or case manager, for the treatment purposes that qualify me for Project Angel Heart’s meal services. The information shared by my health care provider, social worker or case manager with Project Angel Heart may include HIV/AIDS status, psychiatric and mental health disorders, and substance use. I release my health care provider, social worker or case manager and Project Angel Heart from all liabilities and all claims pertaining to the release and disclosure of such information.
Signature
Date
MM slash DD slash YYYY
Applicant Name
DOB
MM slash DD slash YYYY
If signed by personal representative, list authority of personal representative:
Untitled
Untitled
Untitled

Applicant Information

Household Information

Additional comments

Primary Diagnosis

Other Concerns/Diagnosis

Diet

Nutrition education and counseling

Health Care Provider Consent

Referring Health Care Provider

Project Angel Heart Application for Services Consent