Attachment M

CVCOA Meals on Wheels Intake Form

Meals on Wheels of Lamoille County

Personal Information: all information is required!

Last Name / First Name / Aka:
Mailing Address / Town
Zip / Phone / DOB
/ Gender ☐Male ☐Female
☐ Other
Do you live alone?
☐Yes ☐No
Are you a U.S. Veteran?
☐Yes ☐No / Household Size / Monthly Income
1 person / ☐ $981 or below / ☐above $981
2 person / ☐$1328 or below / ☐above $1328
3 person / ☐$1628 or below / ☐above $1628
Race Choose an item. / Ethnicity: Choose an item.

Contact/Emergency Info:

Name / relationship / Day Phone
Name / relationship / Day Phone
Primary Care Physicians Name / Phone

Meal Information for meals delivery use:

Start Date 1 / Start Date 2
End Date 1 / Reason for getting off:
Choose an item. / End Date 2 / Reason for getting off:
Choose an item.
Delivery Days:
☐M ☐T ☐W ☐Th ☐F / # of Frozen meals:
# of Hot meals: / Total # Meals/week / Milk: ☐ Yes Type: Choose an item.
☐ No
Dietary Info: Choose an item. Texture: Choose an item.
Food Allergies:
Reason for needing meals: (check all that apply)
☐Temporary Incapacity ☐Unable to Shop ☐Needs Help with meal
☐Hospital Discharge ☐Unable to Cook ☐Other
☐ Short Term ☐Long Term ☐ Mobility Issues Choose an item.
☐Permanent Incapacity ☐ Homebound Please describe:

Delivery Information:

Physical Address/Directions: including which door to enter, color of house, etc.
Do you have pets? ☐yes ☐no
If yes, is it controlled? ☐yes ☐no / Do you drive a car? ☐yes ☐no
Client referred by? (agency, nh, etc.)
/ Is the client aware of referral?
☐yes ☐ no
Name of person making referral: / Date of referral
Special Notes: Click here to enter text.

Interviewer Check List: Did you explain?

Route Directions / ☐
Database / ☐
New Recipient Packet / ☐
Copy sent to CVCOA / ☐
Last ILA Date
CM:
New Client? / ☐

☐Donation Policy? ☐Confidentiality Policy? ☐24 –hr notice for changes

☐ Home Assessment Policy?

Route or site Referred to: / Info. Taken By / Date

[Publish Date]