Ollie's Plate Intake

Overview

Ollie’s Plate is Ollie Hinkle Heart Foundation’s (OHHF) “Food is Love” initiative to provide heart individuals and families with nutritious meal bundles to make the transition from the hospital to home smoother. We empower families to incorporate healing with nutrient-dense foods into their wellness plans. These services are currently available for individuals and heart families in the St. Louis Region.

OHHF provides discharge meal bundles for low-income individuals or families who are currently inpatient and expect to be discharged within 10-15 days from one of our Missouri partner hospitals.

Please take a few minutes to answer the following questions to help us better understand how to support you through this program.

Note that submission of this application does not guarantee fulfillment of the request. Please be assured that all your information is kept confidential per our privacy policy. OHHF values your privacy and does not share or sell your information to third parties without your written consent. We use the information you provide to improve our services and better understand your needs and the needs of the heart community.

Tell us if you are facing any of these barriers

Please answer the following questions as honestly as possible.

Within the past 6 months, I have worried my family would run out of food before I had money to buy more.

Within the past 6 months, I have worried about or lacked access to transportation to get to medical appointments.

Within the past 6 months, I have had trouble paying my heating or electric bill.

Within the past 6 months, I have had trouble paying medical bills.

Within the past 6 months, I have had trouble with childcare or care for a family member.

Do you feel physically and emotionally safe where you currently live?

Are you worried that in the next 6 months you may not have a place to live?

Are you currently employed?

Are you worried you may lose your job in the next 6 months?

Meal Coordination

Do you live in any of the following areas of St. Louis?

How would you like to receive your meals?

I would like to coordinate receiving the meals in a cold bag on the day we discharge from the hospital.I would like someone to drop off the meals in a cold bag on or around the day we discharge from the hospital.

How far do you live from the hospital from which you will be discharging?

How would you like to receive your meals?

I would like to coordinate receiving the meals in a cold bag on the day we discharge from the hospital.I would like someone to drop off the meals in a cold bag on or around the day we discharge from the hospital.I would like to have the meals shipped to my house.

Shipping

A member of the OHHF team will contact you about shipping your meals directly to your home. Please indicate below if you need items shipped to a different mailing address.

Is the address you provided on the Name & Contact page the best shipping address?

YesNo

Street Address

Street Address 2 (Unit, Apt, etc. or NA)

State

City

Zip Code

References

Please provide two references. These can include your social worker, nurse, physician, or other healthcare provider.

Reference 1

Name (First & Last)

Position/Title

Email Address

Phone Number

Reference 2

Name (First & Last)

Position/Title

Email Address

Phone Number

Consent to Participate in Ollie's Plate

By typing your name below, you are acknowledging and agreeing to the following regarding your request:

I have reviewed OHHF’s website privacy policy and agree with all terms.
I have reviewed OHHF’s client rights and responsibility policy and agree with all terms.
I understand that OHHF has not and will not provide me with medical, legal, or tax advice.
I will complete a client satisfaction survey if approved for discharge meal services.

Type your full name:

Information Authorization

Do you want to authorize additional individuals to discuss and participate in coordinating your services?

YesNo

Authorized Individuals

I hereby authorize the name/s listed below to discuss and participate in coordinating my services through the Community Outreach Program. I understand that if a name is not listed below, Ollie Hinkle Heart Foundation cannot release any information.

Name (First & Last)

Relationship

Type Your Full Name

Initials

Parent	Grandparent	Partner/Spouse
Other caregiver	Sibling	Other

American Indian or Alaskan Native	Asian or Asian American
Black or African American	Hispanic or Latino/a/x
Native Hawaiian or Other Pacific Islander	White or Caucasian
Prefer not to answer	Other

Single Ventricle Heart Defect	Two Ventricle Heart Defect
Transplant	Acquired Heart Condition
Cardiomyopathy	Pediatric Pulmonary Hypertension
Vascular Rings/Slings/Tracheal Rings	Arryhthmia(s)
Other

Infant (birth to 23 months)	Preschooler (2-5)
School age (6-12)	Teen (13-17)
Young adult (18-39)	Adult (40+)

Prenatally	Infant (1 and under)
Preschooler (2-5)	School age (6-12)
Teen (13-17)	Young adult (18-39)
Adult (40+)