2026 FOOD OUTREACH REFERRAL FORM

Food Outreach - Client Referral Form

3117 Olive Street St. Louis, MO 63103 Phone: 314-652-3663
To be completed by healthcare provider or case manager

Questions marked with an * are required.
Patient Information
First Name
Last Name
Today's Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

Zip
Phone
Format: (000) 000-0000.
Alternate Phone
Format: (000) 000-0000.
Preferred Language if not English
Check all that apply:
Race / Ethnicity (Check all that apply)
Number in household supported by income
Using the table above, please choose which percentage tier is the closest to the individuals gross income. Please note, if gross income is greater than 300% the client does not qualify for services.
Treatment Plan
Primary Diagnosis
Cancer Type & Stage
Date of Cancer Diagnosis

MonthDayYear
Date
Patient must be in active cancer treatment to qualify for our services. Please note that maintenance therapy alone does not qualify as active cancer treatment.
If known, please specify medication(s) or regimen name(s):
Treatment Start Date

MonthDayYear
Date
HIV/AIDS Diagnosis Date

MonthDayYear
Date
Ryan White eligible?
CD4 count
CD4 test date

MonthDayYear
Date
Viral Load
Viral Load test date

MonthDayYear
Date
HIV/AIDS Adult Risk Factor

Other
Relevant Medical History
Please describe any special needs or circumstances
Insurance Information
Medicaid
Medicare
Other Insurance / Private Insurance Company
Request Made By
Name (please include credentials LCSW, MD, RD, case manager etc.)
Agency Name and Location
Referrer Phone
Format: (000) 000-0000.
Referrer Email
example@example.com
Treating Oncologist
Oncologist Phone
Format: (000) 000-0000.
HIV/AIDS Physician Name
HIV/AIDS Physician Phone
Format: (000) 000-0000.
Release of Information
By submitting this application, you are confirming that your patient / client has provided verbal consent for their personal health information to be shared with Food Outreach.
Signature of Referring Physician/Social Worker/Nurse/RD/Patient Navigator or Case Manager
Once a referral is submitted, we will attempt to call the individual 2 times to schedule an intake appointment. To expedite the process, please reach out to our Intake Coordinator at 314-710-5543.

Thank you!
Should be Empty:

Food Outreach - Client Referral Form

To be completed by healthcare provider or case manager

Treatment Plan

Insurance Information

Request Made By

Release of Information