CML (01)

Meals on Wheels LeedsHot Meals Service

Referral Details

Service user name
Address
Postcode
Telephone No.
Date of Birth
Next of Kin / Who should invoice be sent to?
Relationship
Address
Postcode
Telephone No.
Keyholder / Yes / No
If No name & phone number of keyholder
Service Specific Details / Comments
Can the service user use the telephone ?
Does the user have speech or hearing or sight problems?
Access details – Door code , big dog, key at No 27 etc.
Does the user have any mobility problems? i.e. Slow to answer door
Please list any allergies to foods
Please list any specific food likes and dislikes
Date meals to start

HOT MEALS SERVICE

Mon / Tues / Wed / Thurs / Fri / Sat / Sun

Please indicate days hot service is required with a tick

TEATIME PACK – Sandwich, light cold sweet snack and water based fruit drink

Mon / Tues / Wed / Thurs / Fri / Sat / Sun

Meals Requirement this section must be completedPlease tick

Traditional meat or fish dishes with potatoes and vegetables
Vegetarian meals
Afro Caribbean meals
Asian Vegetarian meals
Halal meals
Kosher meals
Special dietary requirement
Diabetic
Gluten free
Moderate sodium (Salt)
Low Fat
Reducing
Soft / pureed foods

Name of person making referral

Name Date

Other Comments

Meals at Home Office Use Only

Date of receipt
Acknowledgement letter sent
Date account set up in Civica

The information you provide to Leeds City council will be used by the Leeds City Council Meals on Wheels service and will be used for the purpose of assessing that the proposed recipient is eligible to receive Meals on Wheels or to deal with queries arising from this referral. See Leeds City Councils privacy notice further information

Meals on Wheels – Excellence Award for a making a Difference 2015,2016 and 2017