Client's First Name*:
Client's Last Name*:
Client's Date of Birth*:
Client's Address Line 1:
Client's Address Line 2:
Client's City*:
Client's State*:
Client's Zip Code*:
Client's Home Phone*:
Client's E-mail Address*:
Client's Gender*:
Client's Marital Status*:
Client's Ethnicity:
Does client live alone?*:
If client does not live alone, with whom do he/she live?:
Does client have pets?*:
If so, what kind and how many?*:
Client's Physical Condition:
(Describe client's physical condition. Be sure to mention if the client moves
very slowly and/or cannot hear or see well.)
Why is service being requested?*:
Referred by (name of individual/agency): *
Referrer's phone number:
Referrer's email:
Name of Client's Primary Care Doctor: *
Doctor's phone number: *
Client's Emergency Contact: *
(Relative, friend, or another person whom Meals on Wheels can contact in case of emergency)
Emergency Contact's Relationship to Client:
Emergency Contact's Phone Number*:
Emergency Contact's Address*:
(Please enter the full address for the emergency contact, including street,
apartment/space, city, state, and zip code (and country, if outside the US)
Name of Local Emergency Contact:
(Please enter the full name of a neighbor, relative, friend, or another person
who lives close to client and could easily check on them in case of emergency)
Local Emergency Contact Person's Phone:
Local Emergency Contact Person's Address:
(Please enter the complete address of the local emergency contact person.)
Client's Estimated Monthly Income: *
Total monthly income from all sources, including SSI, investments, etc.:
Client's Monthly Rent/Mortgage Payment: *:
(If client receives assistance with their rent payment/mortgage, enter only the
portion of the rent/mortgage for which the client is responsible.)
What type of diet does client need*:
(Check all that apply. Note: Only regular diet is available in Malibu.)
Client's food allergies and strong dislikes:
Days hot/cold meal delivery is needed:
(Check at least three days for which hot/cold meals are needed. Note: daily
hot/cold meal delivery is not available in Topanga Canyon at this time.)
Client requests weekly frozen meal delivery:
(Frozen meals are not available in Malibu.)
Comments:
(Enter any special instructions, such as different bill-to name and/or address,
instructions for getting into the building, special dietary requests, or
delivery schedule if different from above.)
* Required Field