Application for Services

Current Client Information
Nutritional Risk Assessment
Household Information
Additional Information
Complete

PROGRAM TYPE

Which program type are you interested in? Check all that apply.

Self Pay – NO WAITING LIST (Check, Credit Card, Food Stamps, Cash accepted. $5 per meal full price; $3.80 per meal using SNAP)

Cost-Free - Waiting List. No charge for meals, must meet qualifications.

Hospital Discharge Meals - APPLICATIONS FOR THIS PROGRAM MUST BE SUBMITTED BY HOSPITAL STAFF THROUGH NC CARE 360 PORTAL.

Non-HCCBG Bi-Annual Assessment - ACTIVE CLIENTS ONLY who received an assessment from volunteer.

The Hospital Discharge Meals Pilot Program is a partnership with Meals on Wheels NC and UNITE US NC CARE 360. It is a pilot aimed to evaluate the effectiveness of providing healthy meals to high-risk adults (60+ y/o) after hospital discharge to reduce health complications and hospital readmissions through proper nutrition.

ONLY REFERRALS SENT TO THIS PROGRAM THROUGH NC CARE 360 WILL BE ACCEPTED AT THIS TIME. WE APOLOGIZE FOR ANY INCONVENIENCE THIS MAY CAUSE.

When will patient be home from rehab / the hospital?

*DEPENDS ON QUALIFICATIONS & AVAILABILITY

NEED FOR SERVICE

What is your need for our services? Check all that apply.

Homebound

Living alone

Unable to cook

Unable to shop

CLIENT INFORMATION

First name:

Last name:

Street address:

Apartment Number

Apartment Name

City:

State:

Zip code:

My residential address is:

Rural

Urban

Phone number:

Email address (if any):

Would you like to also receive email or text message notifications from Meals on Wheels?

Gender

Marital Status

Date of birth:

Race

Primary Language

Are you a veteran?

Which of the following best describes your current health or medical insurance coverage. Select all that apply.

Medicaid

Medicare

Private

Not Insured

Prefer not to answer

Other

Do you receive SNAP benefits?

Yes

Do you have a food allergy?

Yes

Please list food allergen(s)

Do you have a disability or impairment?

The Americans with Disabilities Act (ADA) defines a person with a disability as a person who has a physical or mental impairment that substantially limits one or more major life activity. This includes people who have a record of such an impairment, even if they do not currently have a disability. It also includes individuals who do not have a disability but are regarded as having a disability.

Please specify each impairment you may experience:

Questions	None	Some	Total
Hearing	None	Some	Total
Sight	None	Some	Total
Speech	None	Some	Total
Taste	None	Some	Total
Smell	None	Some	Total
Cognitive Difficulties	None	Some	Total

Do you use the following mobility aids? Select all that apply.

Cane

Walker

Wheelchair

Non-ambulatory

Does not use mobility aid

Prefer Not to Answer

Additional Information (if any)

Do you belong to a church / synagogue / mosque / faith community?

Yes

If so, please let us know the name of your faith community.

How did you hear about Meals on Wheels Durham?

Other

×*Meals on Wheels Durham processes meal service applications on Tuesdays and Thursdays.*

*ONLY REFERRALS SENT TO THIS PROGRAM THROUGH NC CARE 360 WILL BE ACCEPTED AT THIS TIME. WE APOLOGIZE FOR ANY INCONVENIENCE THIS MAY CAUSE.*

ONLY REFERRALS SENT TO THIS PROGRAM THROUGH NC CARE 360 WILL BE ACCEPTED AT THIS TIME. WE APOLOGIZE FOR ANY INCONVENIENCE THIS MAY CAUSE.