Homebound Intake Form

* - Required Field
 Español  Polskie  português

If you are an individual who is homebound due to physical restrictions, medical conditions, or other chronic physical or mental health conditions, and therefore cannot attend a community clinic, please fill out this form.. If you fill out this form, a person in your town will contact you. We will only share your information with that person. That person will help you get a COVID-19 shot. Please be patient, information is shared with towns once a week on Mondays. You do not have to fill out this form if you have another way to get the COVID-19 shot.

If you only need a ride to get a COVID-19 shot, you should not complete this form. You should click on this Transportation Resources link for help finding a ride.

For frequently asked questions, please visit: COVID-19 Vaccinations-FAQs (ct.gov).

 Yes  No *

Information of Homebound Person

 Yes  No *
 Yes  No *







*

*
 First Dose  Second Dose  Booster Dose  Don’t Know *