What program is the application for? What program is the application for?Meals on WheelsLiquid NutritionCongregate Dining

First Name

Last Name

Clients Phone Number

Birthdate

Email Address

Address:

Zip Code

County of Residence

Can the client drive? Can the client drive?YesNoNo, due to lack of vehicle.

If yes to driving, how frequently? If yes to driving, how frequently?Multiple times each dayDaily3-5 times per week1-2 times each weekOnce a weekOnce a monthN/A (or not driving)

Able to use public transportation? Able to use public transportation?YesNoYes but they don't need it

Able to prepare meals alone: Able to prepare meals alone:YesYes but microwave only.NoNo but someone in the home can.

Diagnosed with any cognitive impairments? Diagnosed with any cognitive impairments?YesNoNo but they show early signs.

How many people live at the household? How many people live at the household?Lives aloneLives with spouseLives with familyLives with caregiverLives with family member that is the caregiverLives in a facility (Nursing Home, Skilled Nursing, retirement village, etc.)Other

Emergency Contact Name (Mandatory)

Emergency Contact Number (Must be working and active)

Caseworker/social worker name:

Caseworker/social worker number (must list extensions):

Caseworker/social worker reason for referral (must be completed):

Client is substantiated with APS (Requires HCDSS verification)? Client is substantiated with APS (Requires HCDSS verification)?YesNo

Primary Physician Name:

Primary physician phone number (must be on file):

Name of Person Completing this form:

Number of person completing this form: