God s Love We Deliver Grocery Bag Referral Form Page 1 of 6. Grocery Bag Program. Fax: Phone:

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1 Grocery Bag Referral Fm Page 1 of 6 About the Program: Grocery Bag Program Fax: mslate@glwd.g Phone: God s Love We Deliver (GLWD) grocery bag program is designed to provide medically stable clients with HIV/AIDS with one meal a day f a seven-day period. Consequently, each bag should meet 1/3 of the client s estimated daily nutritional needs f calies, carbohydrate, fat and protein. On average, one week of meals will meet the New Yk Department of Health meal content guidelines and will reflect the overall dietary needs of clients with multiple issues, such as dyslipidemia, glucose intolerance and hypertension. Contents will include non-perishable items such as pasta, canned salmon, soup, canned fruits and vegetables, along with fresh vegetables. How It Wks: A delivery of a grocery bag is made to a client s home once a week between the hours of 8:00am and 4:00pm. The delivery day is determined by the client s zip code, either Wednesdays Thursdays Fridays. Clients must agree to be home to receive their grocery bag delivery on the designated day. Clients will also receive a Nutrition Handbook and recipes of the week, prepared by the Nutrition Department Staff at GLWD, to assist them in preparing meals f themselves and staying healthy. Eligibility and Referrals: People diagnosed with HIV AIDS, living within the five boughs of NYC are eligible f the program. Referrals can be made by an agency representative, including case manager, social wker, nutritionist primary care provider, by providing the following: 1. Grocery Bag Eligibility Fm 2. HIPAA release fm 3. CD4 and Viral Load (current within 3 months) 4. One (1) Proof of income (Benefits Card, ADAP card, award letter, budget letter, epaces etc) 5. One (1) Proof of residence (state ID card, utility bill, phone bill, rent, lease, residence letter, SSI SSD award letter, epaces, etc.)

2 Grocery Bag Referral Fm Page 2 of 6 To complete enrollment, a brief phone interview will done with our Client Services Department. F further infmation regarding this program, please call Client Services at Nutrition Services at First Name: Middle Initial Last Name Date of Birth: / / Address: City: State: Zip Code: Client Home Phone: ( ) - Cell Phone: ( ) - Gender: Male Female Transgender (Male to Female) Transgender (Female to Male) Other Sex at Birth Gender Sexual Orientation Race: Black White Asian Native Hawaiian/Pacific Islander American Indian/Alaskan Native Other (Specify: ) (if Asian selected)asian Detail Asian Indian Chinese Filipino Japanese Kean Vietnamese Other Asian (if Native Hawaiian/Pacific Islander selected)native Hawaiian/Pacific Islander Detail Asian Indian Chinese Filipino Japanese Kean Vietnamese Other Asian (if Hispanic selected)hispanicdetail Mexican, Mexican-American, Chicano/a Puerto Rican Dominican Cuban Another Hispanic, Latino/a, Spanish Language Primary Diagnosis: HIV+, Not AIDS HIV+, AIDS status unknown CDC-Defined AIDS Primary Care Provider s Name: Title: Agency/Hospital Telephone #: Fax#: Referral sources name: Title: Referral sources signature: Date: Agency: Phone: Fax:

3 Grocery Bag Referral Fm Page 3 of 6 This referral will include: HIPAA Release Fm (which includes your agency and the primary care provider) Current CD4 and Viral Load Proof of Residence Proof of Income HIV Diagnosis Date: / / If AIDS, AIDS Diagnosis Date: / / HIV Risk Fact: (Check all that apply) MSM IDU Heterosexual Blood transfusion/components Hemophilia/coagulation disder Perinatal Other (Specify ) Unknown Last PCP visit (pri to enrollment): / / Unknown Most recent CD4 Count/Viral Load pri to enrollment: CD4: Date: Viral Load: Date: Is client currently prescribed ART? YES NO If no, why is the client not currently prescribed ART? Not medically indicated Not ready-by PCP determination Intolerance/side effects/toxicity Payment/insurance/cost issue Client refused Other reason Unknown Total number in household (including the client): Current employment status: (Check only one) Please note: clients of God s Love cannot be employed Full-time -time ) Client Resides: Alone w/partner w/family w/dependents under 18: (How many? ) If yes to dependents: the client must verbally confirm proof of all dependents. Highest level of education achieved: (Check only one) No schooling th grade less Some high school High School/GED equivalent Some college Bachels/technical degree Language Spoken: (Check only one) English Spanish Other (Specify: ) If primary language is not English, secondary language spoken: (Check only one) English Spanish Other (Specify: ) Country of birth: (Check only one) USA -Specify: ) country (Specify: ) If not USA, in what month and year did client first come to the USA? Annual Household Income: Uninsured (If Insured, complete insurance details below.) Check all that apply, and complete the related details/dates on each checked insurance type: Insurance Type Insurance details Effective Date End/Expiration Date

4 Grocery Bag Referral Fm Page 4 of 6 (mm/dd/yyyy) / / (mm/dd/yyyy) / / (Check all that apply) / / / / (Check only one plan type) -f-service) / / / / / / / / n litary/va / / / / / / / / Please answer the following questions about the client s substance use. Client states they have never used any of these substances. Has the client ever used: If ever used it, then ask: In the past 3 months? F use in past 3 months, ask: How often do you use? F use in past 3 months, ask: How have you taken this? (Check all that apply) Tobacco times (units) weekly < weekly Orally Smoked Inhaled/snted Alcohol times (units) weekly < weekly Marijuana < weekly Orally Smoked Inhaled/snted PCP/Hallucinogens < weekly Orally Smoked Inhaled/snted Injected Crystal Meth Cocaine/Crack < weekly < weekly Orally Smoked Inhaled/snted Injected Orally Smoked Inhaled/snted Injected

5 Grocery Bag Referral Fm Page 5 of 6 Heroin < weekly Orally Smoked Inhaled/snted Injected Rx Pills to get high < weekly Orally Inhaled/snted Injected Hmones/steroids Client Weight: lbs < weekly Client Height: feet inches Orally Patch Injected In the past three months, how often has it happened that there was not enough money in the household f food? Which of the following best describes your situation in terms of food you eat? This past week, that is in the last seven days, approximately how many cooked meals did you eat? - - In the last 30 days, did you go a whole day without anything at all to eat? Thinking of where you live now, do you: What is the client s current living situation? -SRO hotel) ). Is this an HIV housing program? If yes, check which kind below: Transitional Congregate Transitional Scattered-Site Permanent Congregate Permanent Scattered-Site ogram) Since what date (month and year) has the client been living in this current situation? / (mm/yyyy) How long does the client expect to be in this current living situation? < 1 month - - <6 mo.

6 Grocery Bag Referral Fm Page 6 of 6 Was the client ever homeless? If Yes, when was the client last homeless? / (mm/yyyy) Legal and Incarceration Histy Has the client If Yes, has the client served any time in the p Is he/she eclined

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8 God slovewedeliver 166AvenueoftheAmericas New YkNY10013

9 CLIENT S AGREEMENT WITH GOD S LOVE WE DELIVER I have applied f meal delivery from God s Love We Deliver (GLWD) and I agree to the following: GENERAL POLICY:. I understand that my eligibility f home-delivered meals is based on a valid medical referral fm signed by my doct confirming my diagnosis and all physical and mental limitations as to why I cannot cook and shop f myself. I understand this fm is needed f me to receive services. I understand that GLWD will allow me ten business days to send in a medical referral letter from my medical provider, I will be taken off the program until GLWD receives a valid letter. I also understand that I must obtain a new medical referral letter every six (6) months. I understand that as a requirement f continuing on the meal program, I must complete a nutrition assessment with one of our nutritionists as well as a six-month reassessment my meal service may be interrupted. I also assume full responsibility f keeping GLWD infmed about any and all dietary restrictions, requirements and changes resulting from new diagnoses, medications and/ allergies that of my dependent children. I understand that my deliveries may stop if I do not sign and return this Client Agreement and/ the Client Grievance Policy. Upon receipt of these documents, meal deliveries will restart. I understand that I have the right to contact GLWD regarding a concern, complaint grievance without fear of risking my services and that the issue will be resolved quickly and respectfully. I have received a copy of the Client Grievance Policy, and understand how to make a complaint. I will infm GLWD when I am no longer restricted in activities of daily living and therefe do not qualify f home delivered meals. I understand that I must communicate with respect and courtesy with all GLWD staff and volunteers. I understand that at no time may I cause a GLWD representative to feel be endangered. This includes physical and/ verbal abuse of any kind at any time. I understand that verbal and/ physical abuse to a GLWD volunteer staff member may result in discontinued services based on ineligibility f the meal program. I understand that GLWD will not deliver meals to any household building where a GLWD representative may be endangered. This includes physical and verbal abuse and substance use by the client anyone in the client s household building. This may include other situations deemed dangerous by GLWD. I understand that I may not enter the GLWD building without the permission of the agency at any time. This is to insure my safety and that of any GLWD representative. DAILY RESPONSIBILITIES: I understand that I must be home to receive my meals between 8:00 a.m. and 4:00 p.m. each day that I am scheduled. If I cannot be home, someone must be in my home to receive my meals. If no one will be in my home on my delivery day, I understand that I must cancel my meal delivery hours in advance by calling (212) (800) ing at clientservices@glwd.g. I understand that meals cannot be left with anyone other than myself someone in my home. If I want to be the only person accepting my meals, I understand I must sign a GLWD Proxy Fm and deny allowing anyone to accept my meals. I understand that if I miss up to 3 deliveries (without calling in advance to cancel) - within thirty days - I may be suspended from the meal program f two weeks me. And if I miss in addition to that period, I may be suspended f a period up to thirty days me, based on the discretion of the Manager of Client Services. I understand that if I am not home to receive my meals and have not called in advance to cancel, I will not receive any meal deliveries until I contact GLWD. It may take up to 48 hours to restart meal delivery. Client s Signature: Date: Client Agreement/Client Grievance Policy and Procedure Page 1 of 3

10 CLIENT GRIEVANCE POLICY AND PROCEDURE God s Love We Deliver is committed to maintaining partnerships providing quality services to all of our clients. However, on occasion, you may feel that you have a grievance, a serious complaint, that was not addressed adequately the decision reached was one you did not agree with. The following procedure was developed to address these situations. Step 1: Notify the Manager of Client Services of the grievance. A written rept will be noted in your file and the manager will attempt to immediately resolve the situation. If further follow-up is necessary, the manager will notify the Sr. Direct of Program Services. The Manager of Client Services will notify you within 7 business days of a decision. Notification may be by telephone in writing. If the grievance is the result of a suspension termination of services, the suspension termination of services will continue until the grievance is resolved and a final decision (Step 2) is reached. Step 2: If the situation remains unsatisfacty, you are encouraged to submit your grievance in writing to the Manager of Client Services. Include a description of the concern and include the steps taken to resolve the situation. You may also request a copy of the initial rept submitted. The Manager of Client Services will contact you usually within 7 business days of receipt of your grievance to review the matter. You will receive notification of a final decision within 7 days after contact with the manager. Notification may be by telephone letter. Note: You have the right to have a representative of your choice act as an advocate at anytime during the grievance process. A representative may be a friend, family member, someone in your suppt system. This individual must be reflected on New Yk State Confidentiality fms-the HIPAA fm. Should you request further assistance, you may appeal to the Sr. Direct of Program Services. I have read and understand the Client Complaint and Grievance Policy and Procedure, someone has explained them to me. I have received a copy of the fm. Client s Signature: Date: Please print name: Please review the other side f examples of concerns, complaints and grievances. Client Agreement/Client Grievance Policy and Procedure Page 2 of 3

11 CLIENT CONCERN and GRIEVANCE POLICY AND PROCEDURE GUIDE To enhance the partnership between God s Love We Deliver and our clients, all concerns, complaints and grievances that are brought to the attention of God s Love will be resolved quickly and respectfully. We value your opinions and concerns. Your feedback gives us an opptunity to improve our services to you. You can contact us regarding a complaint without fear of risking your services. The chart below shows examples of concerns, complaints and grievances. It also shows who to call to address and resolve issues. On the other side of this page, you will find an explanation of the Grievance Procedure. Type of Issue Examples of Issues Who to call Potential Result of Call Concern Concern Complaint Complaint Grievance You missed your delivery because you were asleep your dobell was out of der. Your meals have stopped and your medical provider said that you are not eligible f GLWD. Your meal was not delivered until after 4:00 p.m. 3-5 times within the week. Your doct nutritionist says you should have a special diet. You are receiving the wrong food. You have a conflict with a GLWD volunteer staff person and you have been unsuccessful in resolving the conflict. Call Client Services at (212) (800) Call the Manager of Client Services at (212) (800) x131 Call Client Services at (212) (800) Call Nutrition Services at (212) (800) Call the Manager of Client Services at (212) (800) x131 We will likely not be able to return that same day, however we will return on your next delivery day and refer you to an alternative food source, such as a local pantry. We will assist to confirm your eligibility f the meal delivery program with your medical provider. We will advocate f services f you and determine if you are eligible f other meal programs. A Client Services Specialist the Manager of Client Services will contact you to follow-up on resolving your complaint after speaking with the delivery department. The Nutritionist will wk with you and your medical provider to insure that you get the meal that is best f you. The Kitchen and Delivery Department will also be made aware of your complaint. The Manager of Client Services will investigate and follow up with you using the process on the following page. If the Manager deems it necessary, will fward the issue to the Sr. Direct of Program Services the Chief Executive Officer. Client Agreement/Client Grievance Policy and Procedure Page 3 of 3