Meals on Wheels Referral Form

Meals on Wheels Referral Form

If you need to change an existing Meals on Wheels arrangement, please do not use this form but contact HILS directly on: 0330 2000 103 (option 4).

If you are an NHS practitioner looking to access the Hospital Discharge Scheme, please note that a different form is required. Please contact us to request the link.

Meals on Wheels Privacy Notice

1. HILS & Hampshire County Council
HILS is operating as a data processor on behalf of Hampshire County Council. Hampshire County Council complies with the General Data Protection Regulation (GDPR) and is a registered Data Controller (Reg. No Z7534309). Further information can be found on Hampshire County Council’s data protection policies at this link https://www.hants.gov.uk/aboutthecouncil/privacy

2. What information will we ask for?
This form will collect information about you such as your age, address, next of kin and why you are requesting a Meals on Wheels service.

3. What will we use this information for?
We will use this information to check your eligibility for the service and arrange a service for you if you are eligible. If you give consent and you are eligible, we will share your relevant information with Hampshire County Council.

We may need to phone you as part of a sampling exercise to confirm your eligibility for the service.

We may use the information to support the planning or assess the performance of the Meals on Wheels service.

We may use the next of kin and/ or emergency contact details in an emergency or if the driver has concerns, for example, if there is no reply when they try to deliver a meal.

Lastly, we may use the information, if needed, to help us investigate any queries, concerns or complaints you have about the service.

4. How long will we keep this information for?
We will keep the information for as long as is needed to provide a service to you.

5. What if you change your mind?
Our legal basis for the use of your information is your consent. You can change or withdraw your consent for us to hold or use your personal data for the Meals on Wheels service at any time by writing to Meals on Wheels service, Adults’ Health and Care, Hampshire County Council, Third Floor West, EII Court, The Castle, Winchester, Hants SO23 8UQ.
Please note, if you withdraw your consent, we will no longer be able to provide you with the Meals on Wheels service.

6. What are your legal rights?
You have legal rights in respect of the personal information we collect from you. Please see the privacy statement for further details at this link https://www.hants.gov.uk/aboutthecouncil/privacy. You can contact the County Council’s Data Protection Officer at data.protection@hants.gov.uk.
If you have a concern about the way we are collecting or using your personal data, you should raise your concern with us in the first instance or directly to the Information Commissioner’s Office, https://ico.org.uk/make-a-complaint/.

Service information

This is a chargeable service – meals must be paid for. If you/your client is worried about being able to pay for meals, you/they can contact Hampshire County Council for information and advice about financial support.

Hot meal + soup OR dessert price: £9.75

Extra (third course) soup or dessert: £1.75

Tea Pack (Sandwich; plus a snack; plus a dessert): £4.60

You can only order a Tea Pack if you are also having a hot meal. These packs arrive cold and ready to eat the same day. Prices are valid as at 01.02.26 and are subject to annual pricing reviews.

Meals are delivered between 11.15am and 2.15pm, 7 days a week, 365 days a year. We can deliver to any address in Hampshire and 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 0330 2000 103.

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: hampshire@hils-uk.org

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, Access Details, and Risk
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)*
Remove lids - our meals arrive with a film lid that will require peeling backPlate mealEncourage to eatGet cutleryCut up meal
Keysafe code (if applicable)
Keysafe location (if applicable)
Door entry code (for main building)
YesNo
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)
I am referring myselfI am referring a friend or family memberI am a professionalOther
Source of Referral:
Organisation / Team
Referrer Name*

First NameLast Name
Role or relationship to client *
Telephone *
Email (we will confirm receipt of this referral to this email address)*
example@example.com
If you are referring on behalf of a Hampshire County Council social work team, please confirm which team you work for
How did you first hear about HILS?
If you have selected 'other,' or if you would like to provide specific information about how you heard about HILS, or you have an advert code then please provide details below. It is extremely helpful to share this information with us, so that we can better reach the people who need our services.
I confirm that I have obtained their consent to share their personal information with HILS, or have legal authority to consent on their behalf

Payment Details*

We will send a bill at the end of the month for the meals received during that month, so that you only pay for the meals you have received.

A monthly Direct Debit is the easiest and most reliable way to pay for your meals service. We recommend it for three main reasons:

1) Convenience: you won’t have to arrange payments every month;

2) Peace of mind: there will be no missed bills; and

3) Security: payments are protected by the Direct Debit Guarantee. We will send you the Direct Debit forms to complete with your Welcome Pack when you join the service.

To set up your direct debit payments, please call our Finance Team on 01462 887183.
YesNo (if no, please select an alternative below)
If you are unable to pay by Direct Debit, we can also accept payment via: credit or debit card online or over the telephone, cheque or Postal 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.

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.
Credit or debit card (online or over the phone)Cheque Postal Order
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 11.15am and 2.15pm 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.

Where a client has dementia or Alzheimer’s, please provide a named contact who can manage or support with financial matters and account queries. This helps us avoid causing confusion or distress to the client when discussing payments, invoices, or outstanding balances, and ensures communication is handled appropriately and sensitively.

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

PLEASE PRESS SUBMIT

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 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 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.hils-uk.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.
Please verify that you are human*
Should be Empty:

Eligibility

Client's details (person receiving the meals)

Client Support Organisations

Delivery, Access Details, and Risk

Meals on Wheels Service Details

Referrer's (Your) Details

Client Wellbeing

Dietary Information

Nutritional Health

PLEASE PRESS SUBMIT