Client Intake Form“Your Health & Happiness, Our Priority” Name * First Name Last Name Preferred Name Date of Birth MM DD YYYY Phone (###) ### #### Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name First Name Last Name Emergency Contact Phone (###) ### #### Meal Preferences & Dietary Needs Do you have any food allergies? Yes No Do you have any dietary restrictions Yes No What type of meals do you prefer? Home-cooked Pre-packaged No preference Any cultural or religious meal preferences? Health & Mobility Do you have any health conditions we should be aware of? Yes No Do you have any mobility concerns? Yes No Companionship Preferences How often would you like companionship? Weekly Bi-weekly Monthly Do you have any pet allergies? Yes No Would you prefer a companion of a specific gender? Yes No What topics or activities do you enjoy discussing? Hobbies Sports Current Events Books Music Other: Additional Support Needs Would you like assistance with: Grocery Shopping Light Housekeeping Playing Cards Working On A Puzzle Reading And Discussion About A Book Other I understand that Meals With A Friend is a volunteer-based service that provides companionship and meal-sharing opportunities. I acknowledge that my participation is voluntary, and I release Meal With A Friend from any liability related to this program. Client Signature Date MM DD YYYY 🎉 Welcome! We’ve received your Client Intake Form and are so glad you reached out.You're officially one step closer to joining the Meals With A Friend family — a place where friendly visits, meaningful connection, and shared moments matter.We’ll be in touch soon to confirm next steps. In the meantime, feel free to contact us anytime at mealswithafriend@gmail.com or (715) 923-7716.We're honored to support you. 💛
