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    Meals on Wheels Referral Form Hampshire area - private client

    This is a chargeable service – meals must be paid for in advance.  

    The current price for a hot meal and dessert is £11.99 - this includes delivery and a caring wellbeing check.
     
    In addition to your hot main and dessert, you can also order:

    - Breakfast Packs £3.70 (cereal/porridge served with milk, a snack and a drink)
    - Tea Packs £4.60 (sandwich or cream tea, a snack, a dessert)

    - Extra (third course) soup or dessert: £2.10


     
    You can only order a breakfast or a tea meal 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 11.15am and 2.15pm, 7 days a week, 365 days a year. All our prices include delivery and a friendly, caring wellbeing 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: hampshire@hils-uk.org

  • Client's details (person receiving the meals)

  • Date of birth*
     - -
    2 digit day, 2 digit month, 4 digit year
  • If you are filling this form on behalf of someone else, please tick to confirm that:*

  • 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:

  • Delivery and Access Details

  • Can our staff help by doing any of the following when delivering the meal?

  • Meals on Wheels Service Details

  • Start Date *
     - -
    2 digit day, 2 digit month, 4 digit year
  • End Date (only required if meals are needed for a short time)
     - -
    2 digit day, 2 digit month, 4 digit year
  • Please select the days that a hot meal and dessert is required:
  • Please select the days that a Breakfast Pack is required (can only be delivered with a hot meal):
  • Please select the days that a Tea Pack is required (can only be delivered with a hot meal):

  • 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. 
  • Please tick the box(es) below if there is anything that we may need to be aware of with regards to the client:

  • 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. 
  • Please indicate any allergies below:*

  • 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 indicate any dietary preference below: * 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).
  • If the client has a swallowing issue and has been advised to have texture modified meals by a Speech & Language Therapist, please indicate which texture is required: **

  • If the client does not have any swallowing concerns but may benefit from meal options which they may find easier to chew, please speak to the site support teams. 


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

  • 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?
  • 2. Have you/your client lost a lot of weight unintentionally in the past three to six months?
  • 3. Have you noticed that your/your clients’ clothes or rings have become loose recently?
  • 4. Have you/your client recently lost your/their appetite and / or interest in eating?

  • 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:
  • Alternative payment methods (to be agreed with HILS’ Finance Team):

  • 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:

  •  
    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

  •  -
  •  -
  • Please tick where applicable

  • 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

  •  -
  •  -
  • Please tick where applicable:

  • 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.

  • 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.

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