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Holiday Gift Shop Application

Please complete the application below for each eligible client. Applications are due as soon as possible, but no later than Monday, November 28, 2022. Once you submit the form, you will receive a copy of the application via email for your records.

As the staff member submitting this form on behalf of your client, you are responsible for shopping for your client’s gifts in the Community Room in the Langhorne office between December 14-19, 2022. We will email you when you can sign up for shopping time slot(s).

If you have any questions, please contact Anne Marie Richards at or 215-757-6916, ext. 218. Thank you.

  • Case Manager/Clinician's Information

  • Client's Information

  • First NameLast NameAge 
    To be eligible to receive gifts from the Holiday Shop, all gift recipients must be immediate family members and live in the same household as the client. If the client is a child/teen, please make sure you include them in this list.

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