Meals on Wheels Referral Form

Meals on Wheels Referral Form Bedfordshire

This is a chargeable service – meals must be paid for in advance.
 
In addition to your hot main and dessert, you can also order:
- Tea Packs (sandwich or cream tea, a snack, a dessert)
- Breakfast Packs (contains: cereal or porridge with milk, a pastry or snack, a drink)

You can only order a tea meal or breakfast if you are also having a hot meal. These packs arrive cold and ready to eat the same day or next day.

Meals are delivered between 11.30am and 2.00pm, 7 days a week, 365 days a year. All our prices include delivery and a friendly, caring welfare check.

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, on our website, 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

Client's details (person receiving the meals)
Name*

First NameLast Name
Address Line 1*
Address Line 2
Town*
County*
Postcode *
Telephone (main)*
Telephone (other)
Email
example@example.com
Date of birth*

DayMonthYear
Date
Gender
Ethnicity
We are required for monitoring purposes to collect the ethnicity of all our clients to ensure the equality of our service. Please select the client’s ethnicity from the list above
If you are filling this form on behalf of someone else, please tick to confirm that:*

The client has been made aware of this referralThe client has been made aware of the charge for meals

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:
Name of home care provider
Home care telephone number
Name of community alarm provider
Community alarm telephone number
GP Surgery
GP Telephone number
Other support organisation
Other support phone number

Delivery and Access Details
How would the client like us to deliver to them or access their home? (e.g. would the client like us to bring their meal into the lounge, or meet them at the door)*
Can our staff help by doing any of the following when delivering the meal?

Remove lidsPlate mealEncourage to eatGet cutleryCut up meal
Keysafe code (if applicable)
Keysafe location (if applicable)
Door entry code (for main building)
Any other access information (for instance, if the property is hard to find, is up flights of stairs, has limited parking, etc.)*
Is there anything that could pose a risk to our staff when delivering? (for instance, others in the household, dogs that don’t like visitors, etc.)*

Referrer's (Your) Details
I am the client (self-referral)
Name*

First NameLast Name
Role or relationship to client *
Organisation (if applicable)
Telephone *
Email (we will confirm receipt of this referral to this email address)*
example@example.com
How did you hear about HILS?
If you are filling this form in on behalf of someone else:

I confirm that I have obtained their consent to share their personal information with HILS, or have legal authority to consent on their behalf

Nutritional Health

Please answer the following questions about your nutritional health:
1. Are you/your client or your/your client’s family concerned that you/your client may be underweight?

YesNo
2. Have you/your client lost a lot of weight unintentionally in the past three to six months?

YesNo
3. Have you noticed that your/your clients’ clothes or rings have become loose recently?

YesNo
4. Have you/your client recently lost your/their appetite and / or interest in eating?

YesNo

Payment Details*

Meals must be paid for in advance over the telephone by card, online via our website, direct bank transfer or standing order. In some circumstances we can accept payment via an Allpay card or standing order once you have spoken to our Finance Team to agree this. We never accept cash.

Every month we will send you a statement showing the meals you have received, and anything owed, you can then top up your credit for the following month if you wish to continue receiving meals.

If meals are cancelled before 8.30am on the day of delivery you will not be charged for them – any meals cancelled after 8.30am on the day of delivery will be charged.
Payment method:

Credit or debit card (online or over the phone)Cheque Postal Order
Alternative payment methods (to be agreed with HILS’ Finance Team):

Allpay cardStanding order
If someone other than the client is paying for the meal, please list their details here, and ensure their preferred payment method is selected above:
Alternative payer details

First NameLast Name
Relationship to client
Email
example@example.com
Address

Street Address

Street Address Line 2

CityCounty

Post code
I confirm that the payer above is aware and has given consent for their details to be shared with us and to be contacted regarding the client’s bill:

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. We can provide a better service if we have an emergency contact who is available between 11.00am 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.
First Support Contact
Name *

First NameLast Name
Phone (primary) *

Area CodePhone Number
Phone (other)

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Relation to client*
Please tick where applicable

Support contact is a keyholderContact about client whereaboutsContact about client health & wellbeingContact about client finances
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
Name

First NameLast Name
Phone (primary)

Area CodePhone Number
Phone (other)

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Relation to client*
Please tick where applicable:

Support contact is a keyholderContact about client whereaboutsContact about client health & wellbeingContact about client finances
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.
Consent:*

I confirm that the support contacts above are aware, and have given consent, for their details to be shared with us and to be contacted in case of emergency

END OF FORM

Thank you for completing this referral form. Click submit below to complete the form, otherwise we will not receive your referral. You will receive a copy of this form to the relevant referrer email if provided. If you have any questions or comments about the information provided, please email hertsmeals@hils-uk.org.
Please verify that you are human*
Should be Empty:

Client's details (person receiving the meals)

Client Support Organisations

Delivery and Access Details

Meals on Wheels Service Details

Referrer's (Your) Details

Client Wellbeing

Dietary Information

Nutritional Health