Bright Sprout Meals — Medicaid Meal Support Program

Personal Information

Please begin with the eligible individual (typically the mother in cases of pregnancy or postpartum).

First Name *

Please enter your first name.

Last Name *

Please enter your last name.

Your Date of Birth *

Please enter your date of birth.

Contact Information

Phone Number *

Please enter a valid phone number.

Cell Phone Number *

Please enter a valid cell phone number.

Email *

Please enter a valid email address.

Address Information

Address Line 1 *

Please enter your street address.

Address Line 2

City *

Please enter your city.

State *

Please select your state.

Zip Code *

Please enter a valid 5-digit zip code.

Referral Source (optional)

How did you hear about us? Who referred you?

Optional — if someone referred you, let us know who so we can thank them.

Eligibility Screening

Consent, services you need, and questions about your living situation, utilities, food security, and home conditions.

Please provide your consent to be connected with services that can support your needs. * I hereby provide my consent to be referred to HRSN services to address my identified needs I hereby decline referral to HRSN services and understand that by declining, I will not receive these services at this time

Please select an option.

Please select the services you're interested in: *

Select only the services most important to you right now. Honest responses help us prioritize requests fairly and serve more families effectively.

Fresh meals and produce Appliance support None of the above

Please select at least one option.

What is your living situation today? * I have a steady place to live I do not have a steady place to live I have a steady place to live today, but I am worried about the future

Please select an option.

Do you currently receive any form of government housing assistance (Section 8, CityFHEPS, or another housing program)? * Yes No

Please select an option.

In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home? * Yes No Already shut off

Please select an option.

Within the past 12 months, have you worried that your food would run out before you got money to buy more? *

Note: If you answer Never true you will not get approved for our services. Please answer truthfully.

Often true Sometimes true Never true

Please select an option.

Think about the place you live. Do you have problems with any of the following? * Pests such as bugs, ants, mice Mold Lead paint or pipes Lack of heat Oven or stove not working Smoke detectors missing or not working Water leaks None of the above

Please select at least one option.

Eligibility

Are you a Medicaid recipient? *

Note: This program is for Medicaid recipients only.

Yes No

Please select an option.

Medicaid ID Number (CIN) *

Found on your Medicaid benefit card.

Please enter your Medicaid ID number.

Are you Pregnant or Postpartum? * Pregnant Postpartum None of the above

Please select an option.

If pregnant or postpartum, what is the Due / Postpartum date?

Please enter the due date or postpartum date.

Leave blank if this doesn't apply to you.

Do you confirm that the information you provide during this assessment is accurate and complete to the best of your knowledge? * I attest the information provided is accurate and complete to the best of my knowledge I do not attest that the information provided is accurate and complete

Please select an option.

Does the member have serious difficulty walking or climbing stairs (5 years old or older)? * Yes No

Please select an option.

Would you or a caregiver be able to prepare and serve adequate, nutritious meals if supplied with ingredients and instructions?

Note: If you answer yes you will not get approved for our services. Please answer truthfully.

Yes No

Are you currently receiving home-delivered meals or food services through a NYS social services program? *

Examples: Meals on Wheels, home-delivered meals for seniors, or other NYS food assistance.

Yes No

Please select an option.

Currently receiving WIC? * Yes No

Please select an option.

Currently receiving SNAP? * Yes No

Please select an option.

Indicate your monthly SNAP benefit amount. *

Please enter your monthly SNAP benefit amount.

Does anyone in the house have allergies? Yes No

Additional Notes

Household & Family Members

Spouse First Name

Spouse Last Name

Spouse Date of Birth

How many additional children under 18 are in your household?

Including yourself, how many people live in your household? *

Please enter how many people live in your household.

Children's names & dates of birth (one per line, if applicable)

Nutrition Assessment

Email *

Please enter a valid email address.

Full Name *

Please enter your full name.

Age *

Please enter your age.

Date of Birth *

Please enter your date of birth.

Gender *

Please select an option.

Are you currently married? *

Please select an option.

Primary Phone *

Please enter a valid phone number.

Household Size *

Please enter household size.

Primary Address *

Please enter your primary address.

Occupation

Employer

Emergency Contact Name *

Please enter an emergency contact name.

Relationship *

Please enter the relationship.

Emergency Contact Phone *

Please enter a valid phone number.

What are your primary health and nutrition concerns? *

Share any health or food needs and why meals would be helpful.

Please describe your primary health and nutrition concerns.

Health & Medical History

If you selected Other, please describe

Family History

Have any of your close relatives (parent, sibling, child, grandparent) been diagnosed with the following? Please check those that apply.

Heart Disease High Blood Pressure High Cholesterol Cancer (type)

For any conditions above, include the family member's name and age of onset (and cancer type if applicable).

Are you currently taking any medications? * Yes No

Please select an option.

Are you currently taking any supplements? * Yes No

Please select an option.

If yes, list medications (dosage, frequency, start date)

If yes, list supplements (dosage, frequency, start date)

Health Measurements

Height *

Please enter your height.

Current Weight *

Please enter your current weight.

Weight 1 Year Ago *

Please enter your weight from 1 year ago.

Is weight loss/gain a goal of yours? * Yes No

Please select an option.

Have you recently lost or gained weight that concerns you? * Yes No

Please select an option.

If yes, please describe

Lifestyle

Exercise / Activity? * Yes No

Please select an option.

Type(s)

How often and how long?

Sleep Duration *

Please select an option.

Ever had psychotherapy/counseling? * Yes No

Please select an option.

Tobacco use? * Yes No

Please select an option.

If yes, type Cigarettes Vaping Chewing tobacco

Packs per day

Number of years

How often do you have a bowel movement? *

Please select an option.

Please check any concerns that apply to you.

Diarrhea Constipation Heartburn Abdominal cramps/spasms Excess gas Uncomfortable fullness Nausea / Vomiting Appetite concerns Frequent antibiotic use

Other concern (describe)

Food & Dietary Habits

Do you follow a special diet or nutritional program? * Yes No

Please select an option.

Any adverse food reactions (allergies/intolerances)? * Yes No

Please select an option.

Any specific foods you dislike or avoid? * Yes No

Please select an option.

What percentage of meals do you eat out? *

Please select an option.

If special diet — describe

If adverse reactions — explain

If dislikes/avoids — describe

Where do you eat out?

Who does the grocery shopping? (name) *

Please enter the grocery shopper's name.

Daily Dietary Intake

Usual breakfast foods *

Please describe your usual breakfast foods.

Usual lunch foods *

Please describe your usual lunch foods.

Usual dinner foods *

Please describe your usual dinner foods.

Snack foods *

Please describe snack foods.

Vegetables eaten daily? Which ones? *

Please list vegetables you eat daily.

Fruits eaten daily? Which ones? *

Please list fruits you eat daily.

What proteins do you consume most days? (Check all that apply) *

Please select at least one protein type.

Do you eat dairy products daily? * Yes No

Please select an option.

If yes, which dairy do you eat daily?

Other grain (describe)

Birthing People Only

Complete this section if applicable.

Are you currently pregnant? Yes No

How many weeks pregnant?

Expected due date

Are you breastfeeding? Yes No

Any issues you are currently facing? Yes No

If yes, explain the issues

Do you drink caffeinated beverages? Yes No

If yes, what?

Do you drink any alcohol? Yes No

If yes, what / frequency?

What and how much do you drink daily?

Anything else you'd like to share or discuss during your visit?

Review & Submit

The section below is for staff use only — please leave blank unless instructed otherwise.

Nutrition Signature (staff use only)

Printed Name (staff)

Date (staff)

I confirm the information I provided is accurate and complete to the best of my knowledge, and I consent to Bright Sprout Meals storing and using this information for program enrollment and coordination. *

Please confirm to submit your application.

Nourishing meals for growing families.

What you receive

Real food, real support, real care.

Fresh & Prepared

Prenatal & Postpartum

Private & Secure

Delivered to You

Apply for the Meal Support Program

Medicaid Meal Support — Intake Form

Personal Information

Contact Information

Address Information

Referral Source (optional)

Eligibility Screening

Eligibility

Household & Family Members

Nutrition Assessment

Health & Medical History

Family History

Health Measurements

Lifestyle

Food & Dietary Habits

Daily Dietary Intake

Birthing People Only

Review & Submit

Thank you for your submission!

There was a problem submitting your application.

From application to your first delivery

1. Apply

2. Get Approved

3. Receive Meals

Frequently Asked Questions