Meals on Wheels Referral Form

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

Are you located in Mecklenburg County, NC?*

We currently serve neighbors in Mecklenburg County. If you live outside this area, please check for a local Meals on Wheels program near you.

Yes

Name*

Birthdate*

Today's Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

E-mail Address

Adding your email opts you in to receive news including updates about meal deliveries or cancellations and monthly invoices.

Sex*

Race*

Veteran?

Yes

Income Information

This information helps us determine eligibility and prioritize services. Your responses are kept confidential. If you’re unsure of any amounts, you may estimate or skip the question. Our team will follow up if needed.

About how much is your total household income per month (before taxes)?

Estimates are okay. You may skip if unknown.

Do you currently receive SNAP (Food Stamps)?

Yes

About how much do you pay each month for rent or your mortgage?

Estimates are okay. You may skip if unknown.

About how much do you pay per year in property taxes and/or HOA fees?

Estimates are okay. You may skip if unknown.

About how much do you spend each month on out-of-pocket medical expenses?

This may include prescriptions, doctor visit co-pays, over-the-counter medical supplies, supplemental insurance, or in-home care not covered by insurance. Estimates are okay. You may skip if unknown.

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Yearly Property Taxes/HOA Fees divided by 12

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Income Information Total

Emergency Contacts

Emergency Contact 1 Name

Relation

Phone (Cell)

Phone (Work)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address

Emergency Contact Name 2

Relation

Phone (Cell)

Phone (Work)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address

Other Information

Primary Care Doctor*

Doctor's Office – Phone

Doctor's Office – Fax

Known Medical Conditions*

Known Food Allergies

Dietary Needs

Chopped Meats

Consistent Carbohydrate

Gluten Free

Puree

Regular

Renal

Renal Diabetic

Soft

Vegetarian

Resides

Alone

With family

With one other person

Pet(s)

Dog(s)

Cat(s)

Has Access to

Conventional Oven

Microwave

Vision

Good

Fair

Poor

Hearing

Good

Fair

Poor

Dental

Has own teeth

Dentures

Now eats soft foods

Yes

Mental Status

Alert

Oriented

Depressed

Alzheimer’s

Confused

Forgetful

Difficult

Have you received groceries/temporary food assistance from Nourish Up (formerly Loaves & Fishes/Friendship Trays) before?

Yes

Preferred language

(for calls and written materials)

English

Spanish

Other

How did you hear about Nourish Up / Meals on Wheels?*

This helps us understand how neighbors find us.

If “Other,” please tell us how you heard about us

Referred by*

Referral Code (If applicable)

Phone (Cell)

Phone (Work)

Relation

Comments

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Meals on Wheels Referral Form

Apply for Meals on Wheels

Income Information

Emergency Contacts

Other Information

New Name, Same Mission