Get Home Delivered Meals in Hillsborough County

Referral Intake Form

Are you requesting services for yourself or someone else?

Requester Information

First Name

Last Name

Phone Number

Your Relationship to Client

Is the Client aware of the referral?

If the potential participant is unable to complete the enrollment process themselves, who should we contact

Does the individual have any communication access needs?

If yes, please share what accommodations are needed/requested

Other Enrollment Contact

Enrollment Contact First Name

Enrollment Contact Last Name

Enrollment Contact Phone Number

Enrollment Contact Relationship

Client Information

Client First Name

Client Last Name

Phone Number

Client Email

Primary Language

Street Address

City

State

Zipcode

Date of Birth

Age

CFI Case Manager

Is Service Authorization in MMIS?

Service Authorization Start Date

Service Authorization End Date

Approved Weekly Meals

Case Manager First Name

Case Manager Last Name

Case Manager Agency Name

Case Manager Email

Case Manager Phone Number

HCMOW can begin home delivered meal service when participant's active Service Authorization is uploaded in MMIS

APS Case Manager

Is participant active under APS?

Date of APS Eligibility

Over 60

Do you have a limited capacity to prepare Meals?

Limited Ability to Leave Residence?

Unable to use Community Dining?

Please share your need for Meals on Wheels

Is Monthly Income under $1,600.20?

Is the participant homebound?

Participant is Homebound

Share Chronic Conditions

Not Eligible

Based on your response, you may not be eligible for our home-delivered meal program. If you would like an Enrollment Specialist to contact you regarding your eligibility or to provide information on local resources, please SUBMIT this form.

Additional Client Questions

How did you hear about HCMOW?

Are they currently receiving home delivered meals from another service?

Demographics

Gender

Hispanic

Race

Marital Status

Veteran

Spouse of Veteran

Living Arrangement

Monthly Income

Pets in the Household

Additional Pet Questions

# of Cats

# of Dogs

Other Pets

Would you like more information about our PETGO program? PETGO is a partnership between HCMOW and the Animal Rescue League of NH and Greater Nashua Humane Society to provide essential pet food and cat litter to HCMOW home-delivered meal clients.

Dietary Restrictions

Additional Dietary Restrictions Question

Known Food Allergies

HCMOW offers gluten-free, lactose-free, and puréed menu options. For more details about the nutritional content of our meals, please refer to the sample menus available on our website.

Within the past 12 months, I/we worried whether our food would run out before we got money to buy more.

Often True Sometimes True Never True

Within the past 12 months, the food I/we bought just didn't last we didn't have money to buy more.

Often True Sometimes True Never True

Contact Information