Enhanced HCNS Meals on Wheels Referral Form - Hertfordshire

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    HCNS Enhanced Support Referral Form 

    This is a referral form for HCNS Enhanced Support. This can be used to request: Meals on wheels, Emergency Food Packs, and/or Community Navigator support.

    Clients can receive daily meals on wheels fully funded for 14 days under this service as well as breakfast and tea packs if needed (all meals are delivered at the same time during our lunch time delivery slot).

    Clients are able to stay on the service for longer if the client is able to pay for their meals beyond the initial fully funded period.

    Clients can receive an emergency food parcel which can either be 3 or 7 days’ worth of food.

    Clients can receive a wide range of support from the Community Link Worker Service, please indicate if this is required.


    Provision of personal data: we cannot provide a service without a minimum amount of personal information. These sections of the form are mandatory on this form. Please ensure that you have the client’s permission to share their data, if you are completing the form on their behalf. Please see our full privacy statement at the end of this form, or give us a call on the number above.

    Before you start

    You can save the form at any time and return to it later by clicking the save button at the end of each page. If you do not want to create an account, you can skip this and either copy the link to your form, or provide an email address to receive a link to your draft form. Remember to click submit once you have completed the form. 

    If you have any issues completing this form, please email: hertsmeals@hils-uk.org

  • Support Required

  • Please be aware that if you are referring a client for an Emergency Food Parcel and they are not being discharged from hospital, the following form must be used: 

    https://form.jotform.com/hilsteam/emergency-food-grocery-pack

  • Client's details (person receiving the service)

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  • Client Support Organisations

    Sharing information about other services or organisations which support our clients, will help us to keep clients safe. This information will only be used to protect clients’ vital interests. Please provide this below:

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    Client Support Contacts
     
    It is very important that we have details of other people who we can contact if we have any concerns regarding the client’s health, safety, finances, or wellbeing.

    For clients receiving meals on wheels:

    We can provide a better service if we have an emergency contact who is available between 11.30am and 2.00pm to answer the phone if required.

    This is in case a client is not at home when we attempt to deliver, we cannot find the client, and we are concerned for their welfare. We understand that not all contacts will be able to perform all support functions, so please tick the boxes to indicate who we should contact in which situation. If you can provide more than two contacts, please email these to us along with your form. Where possible please provide a mobile phone number. 

    If you do not have any contacts, please call our friendly team who may be able to help.

  • First Support Contact

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  • Please note that unless you have indicated above that a support contact may be consulted regarding specific matters related to the client, we will be unable to discuss these matters with them.

  • Second Support Contact

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  • Please note that unless you have indicated above that a support contact may be consulted regarding specific matters related to the client, we will be unable to discuss these matters with them.

  • Referrer's (Your) Details

  • Client Wellbeing

    We are required by the Care Act 2014 to ensure that: reasonable adjustments are made to adapt services to suit individual needs (such as providing specialist meals); and that we alert statutory services if we have sufficient information that a client is experiencing, or at risk of, abuse or neglect. We also have a duty to safeguard our staff, and therefore need to know about any possible risks to their safety. 

  • Delivery, Access Details, and Risk

  • Risk

  • For Food Parcel Deliveries Only

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  • If you are only referring for FOOD PACKS or COMMUNITY LINK WORKER support, finish here.

     

    If you are referring for MEALS ON WHEELS, please continue with the form.

    We will not be able to accept a referral unless the whole form is completed. 

     

     

  • Meals on Wheels Service Details

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  • Dietary Information  

    To ensure that the client receives appropriate, safe meals, please complete this section to tell us about their likes and dislikes, any allergies, health conditions, or nutritional issues. Any personal data regarding a person’s health and dietary requirements will be used solely to ensure the food they receive is safe and appropriate for them, in accordance with the 2014 Care Act. 

  • By completing this form, you are confirming the allergy information you have provided is correct and up to date. 

    Please ensure that we are kept informed of any changes in the future.

  • * PLEASE NOTE: If the client has diabetes, all of our meals are suitable; however, they may wish to select desserts that contain less that 15g of sugar (lowest sugar in our range).


  • ** PLEASE NOTE: we are currently unable to provide texture modified tea and breakfast meals. 

  • Health & Nutrition

    Please answer the following questions in relation to the client's nutritional health. If you answer “Yes” to one or more of these questions, you may wish to request a Nutrition & Wellbeing check (please see question 5). Please note that this is a non-urgent service and there may be a waiting list.

  • Other services

    As well as meals on wheels, HILS also delivers a number of other services to help people remain happy, healthy, and independent in their home. If the client is interested in receiving further information about any of our other services, please tick below and our Support Team will get in touch.

  • ****PLEASE NOTE: we can only accept requests for medication prompts from a professional who can confirm that the client has the capacity to manage, dose, and self-administer their medication.

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  • How will your information be used?

    Your personal data will only be used to deliver a safe, caring, and tailored service that meets your individual needs. We will never share your data without your consent unless we believe that you may be in danger or that your wellbeing is at risk. In this case, we would only share the information necessary to help you stay safe and well, and only with the proper authorities (e.g. police, ambulance) and/or your emergency contacts. While it is in our care, your data will be kept securely and only viewed by authorised HILS / AgeUK / HertsHelp staff. All team members are trained in how to keep your data safe and your rights as a data subject, we do not use any automated decision-making or data profiling processes – meaning all decisions regarding your service are made by humans.

    What are your rights?

    HILS, AgeUK, and HertsHelp comply with the General Data Protection Regulation 2016, meaning that we are committed to keeping your personal data safe and will always respect your rights as a data subject. These rights are:

    The right to be informed and to limit data processing – this means that we need to tell you about how we are using your personal data and will only use it in the way we describe above. If we want to use your personal data for anything else, we will always tell you and ask for consent if necessary. You have the right to disagree with the way we process your data and to ask for this to be changed, these requests would be reviewed on a case by case basis.

    The right to access, ask for corrections, and to delete personal data – this means you can ask to see all the data that we hold on you, to ask for data to be changed and/or deleted from our records. 

    The right to data portability – this means that you can request for us to provide you with all the personal data we hold on you in a format that you can take with you (e.g. if you want to take your information to another service provider).

    To find out more about your rights and how HILS processes personal data, please see our Privacy Notice on our website at: www.hertsindependentliving.org/privacy-policy/. You can also contact us via email on data@hils-uk.org or call 0330 2000 103 and ask for the HILS Data Protection Officer.

    Click submit below to complete the form, otherwise we will not receive your referral.

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