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Online Intake Form

Meals on Wheels West serves people of all ages and all incomes. Meals are low cost, and you may qualify for subsidies.

Enroll online or call for delivery to your door: (310) 394-5133 ext. 1

Enroll Now

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*
Date Format: MM slash DD slash YYYY
Age*
Height
Weight
Physical Condition
Why is service being requested ?*
Disability
- Visually Impaired
- Hearing Impaired
- Physically Impaired
- Mentally Impaired
Marital Status*
- Married
- Single (Never Married)
- Widowed
- Domestic Partner
- Divorced
- Separated
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
Comments
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Serving LA Coastal Communities Since 1974

1823-A Michigan Avenue, Santa Monica, CA 90404

(310)394-5133

info@mealsonwheelswest.org

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