Meals on Wheels Referral Form

Meals on Wheels Referral Form

If you are finding this form difficult to fill in for any reason, you can request a paper form to be posted to you by calling 0330 2000 103.

This is a chargeable service – meals must be paid for. The price of a hot meal and dessert is £7.99. If you need support with finances, or require free food parcels due to a crisis, please contact HertsHelp at info@hertshelp.net or on 0300 123 4044.

In addition to a hot meal and dessert, you can purchase Tea Packs (sandwich, or cream tea; plus a snack; plus a dessert) and/or Breakfast Packs (cereal or porridge with milk; plus a pastry or snack; plus a drink). You can only order a Tea Pack or Breakfast Pack if you are also having a hot meal. These packs arrive cold and ready to eat the same day or next day. The prices of these meals are:
- Tea Pack: £4.40
- Breakfast Pack: £3.50
Meals are delivered between 11.30am and 2pm, 7 days a week, 365 days a year. We can deliver to any address in Hertfordshire 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 on our website link below, or give us a call on the number above.

www.hils-uk.org/privacy-policy

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

Eligibility

The person receiving the meals must meet one of the below criteria to be eligible for meals on wheels.
Eligibility Criteria - please ensure that the client meets at least one criteria, and tick the appropriate box(es):*

1. The client has difficulty preparing or cooking a meal because: they are frail, confused, or housebound2. The client has difficulty preparing or cooking a meal because: they have a mental, physical, and/or learning disability3. The client has difficulty preparing or cooking a meal because: they would be at risk in preparing a meal4. The client is unable to shop regularly for food or obtain a meal from any other source5. The client needs temporary cover or service because: their carer is unwell or on holiday6. The client needs temporary cover or service because: they are suffering bereavement, illness, or have recently been discharged from hospital
Client's details (person receiving the meals)
Previous client - please tick here if:

The client has used HILS services in the past
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
Client Consent - 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:
GP Surgery
GP Telephone number
Name of home care provider
Home care telephone number
Name of community alarm provider
Community alarm telephone number
Designated Social Worker
Social Worker Telephone 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 their house, or meet them at the door etc.)*
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)
Should we always use a keysafe to access the client's home?*

YesNo
Should we always use a keysafe to access the client's homex?

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
Please tick this box if you are referring yourself (self-referral)

I am referring myself
Please tick the box that best describes you today:*

I am referring myselfI am referring a friend or family memberI am a professionalOther
Source of Referral:*
Organisation / Team
Organisation (if applicable)
Referrer Name*

First NameLast Name
Role or relationship to client *
Phone Number *
Email (we will confirm receipt of this referral to this email address)*
example@example.com
How did you hear about HILS?*
If you have selected 'other,' or if you would like to provide any more specific information about how you heard about HILS, 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.
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

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.
Payment to be made by Direct Debit :*

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. We never accept cash.
Payment method:

Credit or debit card (online or over the telelphone)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 11.30am and 2.30pm 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
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

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 bear in mind that some of these services may have waiting lists.
Which additional services is the client interested in receiving?

Physical activity and exercise at home (free) Medication prompts / reminders (free) **** Key safe installation (£) Help from an Optician at home (free) Advocacy: help with decision making around your care and support (free) Dementia support (£)Community Hubs, Hatfield (£)Community Hubs, Cuffley (£)Community Hubs, Letchworth (£)
****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.

END OF FORM

Thank you for completing this referral form. You will receive a copy of this form to the relevant referrer email if provided. If you do not receive a copy of this form, or if you have any questions or comments about the information provided, please email hertsmeals@hils-uk.org.

What happens next?

We will process the information recorded in this referral form, and get your meals service up and running for the start date you have requested. There is nothing else for you to do at this stage. We will send you a confirmation by email shortly outlining the details of your service. If we have any questions, we will be in touch by telephone or email. Click submit below to complete the form, otherwise we will not receive your referral.
Should be Empty:

Eligibility

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