NOTE: NeighborShare is currently available only in the Midlands area of South Carolina. As the program builds momentum we will expand to other communities in our state.

Patient First Name

Patient Last Name

Patient Street Address

Patient City

Patient State

Patient Zip

Patient's part of town.

Columbia Area:
DowntownNortheastSt. Andrews/IrmoCayce/West ColumbiaFort Jackson/East ColumbiaNorthwestI do not live in Columbia

If patient lives outside of Columbia, please select their County
(Select from Dropdown Menu)

We are currently only able to serve the South Carolina counties listed in drop-down menu above. If they are not in one of these counties, select "Other" and we will keep their information on file to follow-up as we expand in the future.

Patient Phone (Example "123-456-7890")

Patient Email (Example "")

Thanks for requesting assistance through NeighborShare. Can you tell us a little more about them?

Does patient receive SNAP/EBT?

Does patient have a primary care physician?

If yes, please provide doctor's name:

Does Patient have their own transportation?

Please ask the patient to respond "Yes" or "No" to the following two questions:
1. Within the past 12 months, we worried whether our food would run out before we got money to buy more.

2. Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.

Please share anything else about the patient that you would like us to know.

Please select the level of assistance needed below (Check all that apply):

Referring Case Manager Information
Your Name:

Your Clinic:

Your Email (Example "")

Your Phone (Example "123-456-7890")