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Home-Delivered Meal Program Referral Form

Eligible applicants must be age 60 or over, homebound, unable to drive or utilize public transportation, unable to leave their home independently, unable to shop and/or prepare a nutritious meal, and not be attending a day-time program (e.g., dining program, adult day care program, etc.).*

*An individual under the age of 60 may be eligible with an approved waiver (DHS, PACE, NHPRI, Rhody Health, etc.)

Step 1 of 3 - Person Making the Referral

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Person Making Referral
Name*
First Last
Phone*
Referred by Email Address*
Client Information
Name*
First Middle Last
Gender*
Birth Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Soc. Sec. #
Medicaid #
Home Phone*
Cell Phone
Work Phone
Email
Preferred Language*
Marital Status*
Race/Ethnicity*
Veteran Status*
Living Situation*

Personal Health History
Difficulties (Please check all that apply)*
- Hearing
- Sight
- Speech
- Mobility
- Other
Medical Conditions (Please check all that apply)*
- Cancer
- Depression
- Diabetes
- Heart Disease
- Lung Disease
- Memory Issue
- Mental Health/Psychological Issue
- Osteoporosis/Arthritis
- Parkinson's
- Renal/Kidney Issue
- Stroke
- Weight Loss/Malnutrition
- Other
Please list any other medical problems.
Why do you need Home Delivered Meals? (Please explain any difficulty with meeting your daily needs)*
Primary Doctor*
Health Insurance Provider*
Doctor Phone
Please answer each question below indicating one of the following responses
Activities Of Daily Living
Please put 0 for None; 1 for Some; 2 for Much; 3 for Cannot
Get in and out of bed/chair
Please enter a number from 0 to 3.
Move about in the home
Please enter a number from 0 to 3.
Dress oneself
Please enter a number from 0 to 3.
Feed oneself
Please enter a number from 0 to 3.
Use the toilet
Please enter a number from 0 to 3.
Tend to personal hygiene
Please enter a number from 0 to 3.
Prepare Nutritional meals
Please enter a number from 0 to 3.
Perform light housekeeping
Please enter a number from 0 to 3.
Perform heavy chores
Please enter a number from 0 to 3.
Manage medications
Manage finances
Please enter a number from 0 to 3.
Use the telephone
Please enter a number from 0 to 3.
Shop for oneself
Please enter a number from 0 to 3.
Drives or utilizes public transportation
Please enter a number from 0 to 3.
Please answer the following questions with Yes or NO
Do you have an illness/condition that may change the kind and or amount of food you eat?
- Yes
- No
Do you eat fewer than 2 meals per day?
- Yes
- No
Do you eat few fruits, vegetables or milk products?
- Yes
- No
Do you have 3 or more alcoholic drinks every day?
- Yes
- No
Do you have teeth/mouth problems that make it difficult for you to eat?
- Yes
- No
I don't always have money to buy the food I need.
- Yes
- No
Do you eat alone most of the time?
- Yes
- No
Do you take 3 or more medications each day?
- Yes
- No
Have you lost or gained 10 pound or more in the past 6 months?
- Yes
- No
I am not always able to shop / cook / feed myself.
- Yes
- No
Do you have difficutly getting out unless transportation is provided?
- Yes
- No
Do you lack outside activity?
- Yes
- No

Emergency Contact
Name*
First Last
Phone*
Relationship*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Second Emergency Contact
Name*
First Last
Phone*
Relationship*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Do you have Medicare?
- Yes
- No
Do you have Medicaid?
- Yes
- No
Name
This field is for validation purposes and should be left unchanged.

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Meals on Wheels of Rhode Island
70 Bath St.
Providence RI 02908
(401) 351-6700

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Meals on Wheels of RI, Inc. is a registered 501(c)(3) nonprofit organization.

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Get Meals
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Programs
Give
About Us
Events
- March for Meals
- Festival of Meals

Need help? Call us! (401) 351-6700