Food & Nutrition Services Application

Lifelong’s Food and Nutrition program, Chicken Soup Brigade (CSB), delivers healthy, home-cooked meals and nutritious groceries right to your door. CSB meals are made on-site, from scratch, using whole food ingredients. Our groceries are nutritious and contain enough items from each food group to create 7 meals. Once we receive your application, our Client Services Team will be contacting you if more information is needed and your application will be added to our waitlist.

Our services are 100% free of charge to those who qualify!

Our services are for people who:

Are low income
Are medically vulnerable/have a chronic illness
Find leaving home without help difficult (homebound)
Have a hard time cooking because of physical limitations
Struggle with some daily activities because of physical or mental health conditions

Call our Client Services team if you have any questions at 206-957-1686

Name*

First NameMiddle InitialLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Phone Number*

Alternate Phone Number

Email

example@example.com

Preferred method of contact:

PhoneEmailLetter

Do you have or has a doctor told you that you have one of the following diagnoses? (Please check all that apply)*

On Dialysis?

YesNo

Other diagnoses:*

N/A if no other existing conditions or confirm homebound status

Monthly Income*

Source of income*

Please list your sources of income, e.g. SSI, SSDI

Do you have Medicare*

Do you have Medicaid (Apple Health)*

Gender:

Race:

Ethnicity:

Are you a Veteran?

Are you a refugee/immigrant?

Preferred Language:

Do you need an interpreter?