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

First Name

Last Name

Clients Phone Number

Birthdate

Email Address

What pronouns should we use when addressing this client? What pronouns should we use when addressing this client?He/HimShe/HerThey/ThemOther

Marital Status: Marital Status:MarriedDivorcedWidowedNever MarriedDomestic Partnership

Household Monthly Income (Joint if Married):

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

Who is currently supporting the client? (select all that apply): Who is currently supporting the client? (select all that apply): Parent(s) Children Sibling(s) Neighbor(s) Friend(s) Other non-relative(s) Henderson County DSS Veterans Administration (VA) Support Group or other acquaintance(s) No additional support

What kind of support are they providing? Please be as detailed as possible.

Emergency Contact Name (Mandatory)

Emergency Contact Number (Must be working and active)

Caseworker/social worker name:

Caseworker/social worker number (must list extensions):

Caseworker extension (incomplete data may nullify referral):

Referring agency:

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

Caseworker email (required for APS verification):

Primary Physician Name:

Primary physician phone number (must be on file):

Primary physician fax number (Liquid Nutrition Only):

Name of Person Completing this form:

Phone number of person completing this form:

Why do you and/or the client feel that they need this program? (Please be detailed):

What else do we need to know about this client?

Who should we contact to discuss this persons service? Who should we contact to discuss this persons service? The ClientThe Emergency ContactCaseworkerOther (complete next segment)

If you chose "other", please enter their details here:

Reminder: This form must be completed in it's entirety to be processed. Incomplete forms will receive a rejection notice via email. If rejected, a new form must be submitted.