Online Intake Form

Personal Information

Applicant Name*

First Last

Phone*

Home Address*

Street Address Address Line 2 City State ZIP Code

Type of Residence*

Apartment
House
Hotel

Does the individual*

Rent
Own
Unknown

Driver Instructions

Do you live alone?*

Yes
No

Gender*

Male
Female

Birth Date*

Age*

Height

Weight

Physical Condition

Why is service being requested ?*

Disability

Visually Impaired
Hearing Impaired
Physically Impaired
Mentally Impaired

Marital Status*

Client Race*

Hispanic/Latino
Asian
African American
White
Other

Primary Language Spoken*

Translation needed?*

Yes
No

Do you have pets?*

Yes
No

If yes, what and how many?

Have you ever been homeless?*

Yes
No

Do you identify as LGBT?

Yes
No

Are you a veteran or a spouse of a veteran?

Yes, Veteran
Yes, Spouse
No

Physician Information

Name of Physician

Physician Phone

Physician Fax

Physician Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact

Name of Relative/Friend

Relationship

Relative/Friend Phone

Relative/Friend Address

Street Address Address Line 2 City State ZIP Code

Second Emergency Contact (Optional)

Name of Relative/Friend

Relationship

Relative/Friend Phone

Relative/Friend Address

Street Address Address Line 2 City State ZIP Code

Financial/Insurance Information

Monthly Income*

Rent*

Are you currently receiving SSI/SSP?*

Yes
No

Do you have Health Insurance?*

Yes
No

Do you receive Medi-Cal?*

Yes
No

Do you receive In-Home Supportive Services?*

Yes
No

Is your personal income below $10,830 per year?*

Yes
No

How did you hear about Meals on Wheels West?

Services Requested

Diet*

Regular
Low Sodium
Diabetic
Renal
Low K

Special instructions

Meal Service

MTWTF
MWF

Frozen

5
7
Weekend

Main Contact Information

Name*

First Last

Phone*

Email*

Comments

Phone

This field is for validation purposes and should be left unchanged.

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Personal Information

Physician Information

Emergency Contact

Second Emergency Contact (Optional)

Financial/Insurance Information

Services Requested

Main Contact Information