COPES Food & Nutrition Services Application

COPES Ancillary Services: Meals & Nutrition Counseling Referral Form

Please complete all required fields and authorization(s) in Provider One (https://www.waproviderone.org/) before submitting this form to avoid delays in processing the application. Our COPES vendor number is 628880. You can refer a client for meals or to meet with a dietitian (nutrition counseling) or BOTH.
COPES allows for 14 or 28 meals per month. The program requires a reduction in 30 minutes of covered caregiving per meal.
- For clients who want 14 meals per month, this is equivalent to 7 hours of caregiving.
- For 28 meals per month, it’s 14 hours.
For six (6) monthly visits with a dietitian for nutrition counseling, no exchange of hours is required: It is effectively “free” to all COPES clients. Most visits are done over the phone, but alternatives are available. We encourage you to refer all COPES clients for nutrition counseling.

Questions? Please email foodservices@Lifelong.org or call (206) 957-1686
Referral Information
I am referring this client for:*

MealsNutrition CounselingBoth
Referring Provider Name*
Title
Agency/Hospital
Phone*
Extension
Email*
example@example.com
ProviderOne Authorization Start Date: Meals*

MonthDayYear
Date
ProviderOne Authorization End Date: Meals*

MonthDayYear
Date
ProviderOne Authorization End Date: *

MonthDayYear
Date
ProviderOne Authorization Start Date:*

MonthDayYear
Date
How many meals does the client want per month?*

1428
ProviderOne Authorization Start Date: Nutrition Counseling*

MonthDayYear
Date
ProviderOne Authorization End Date: Nutrition Counseling*

MonthDayYear
Date
Client Information
Client First Name*
Client Last Name*
Pronouns
DOB*

MonthDayYear
Date
Phone Number*
Is the phone a cell phone?

YesNo
Does the client consent to receiving text messages?

YesNo
Email (enter only if client consents to receiving email messages)
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender:

MaleFemaleTransgender M-FTransgender F-MNonbinary
Gender Identity:

MaleFemaleTransgenderNonbinary / gender non-conformingOther
Primary Language
If not English, does this person need an interpreter?

YesNo
Best time to contact client
Person who prepares food and shops for groceries:

Homecare worker/IPFriend/ family memberOther paid providerOther
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Relationship to Client
Health Information:

Attach medical diagnoses and medication sections from most recent annual assessment. Please do not attach entire assessment. If you have this information but cannot include as an attachment, you can enter it under "reason to see dietitian" below.
Problem List

Cancelof
Medication List

Cancelof
Height (inches)
Weight (pounds)
Reason for dietitian to see client:
There's no wrong answer. Some common topics include: digestive symptoms (i.e. nausea or constipation), poor appetite, learning to manage health condition (high blood pressure, diabetes, etc.) with diet, meal prep tips or recipe ideas.
Other Comments or Relevant Information:
Referral Date

MonthDayYear
Date
Should be Empty:

COPES Ancillary Services: Meals & Nutrition Counseling Referral Form

Referral Information

Client Information

Health Information: