MEALS ON WHEELS OF CENTRAL MD APPLICATION FOR SERVICE

Date Received: Region MEALS ON WHEELS OF CENTRAL MD APPLICATION FOR SERVICE MEALS ON WHEELS APPLICATION FOR SERVICE Name: ________________________...
Author: Russell Davis
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Date Received:

Region

MEALS ON WHEELS OF CENTRAL MD APPLICATION FOR SERVICE

MEALS ON WHEELS APPLICATION FOR SERVICE

Name: ______________________________________________________________________________ Last

First

Initial

Street: ______________________________________________________________ City: ________________________________________

State: ____________

Title

Apt #________

Zip:______________

Phone: ________________________________

Cell Phone: ______________________________

E-Mail_____________________________

BIRTH DATE ____/ ____/ ____

SS#_________-_______-________ Marital Status: Married 

Race _______________

Widowed 

Single 

PLEASE PRINT ANSWERS CLEARLY

Veteran  Spouse  Neither 

Rural community Yes  No

Do you speak English? Yes  No

Language(s) spoken ______________________________

If you do not speak English, who can we call to help communicate with you? Translator’s Name

_________________________________ Phone Number

Do you live alone? Yes  No  Who else lives with you? __________________________________ Are there any pets in your home? Yes No

Type of pet

____________________________

Do you need help obtaining pet food? Yes  No  EMERGENCY CONTACT #1 Name: __________________________________________ Relationship: ________________________ Street: ________________________________________________________ Apt #_________________ City: ___________________________ State:____

Zip:_________ E-Mail:______________________

Phone # (H) _______________________ (W) ______________________ (cell) __________________ Does this person have a key to your home? Yes  No  Do we have your permission to discuss medical or other concerns with this person? Yes  No  EMERGENCY CONTACT #2 Name: __________________________________________ Relationship: ________________________ Street: ________________________________________________________ Apt #_________________ City: ___________________________ State:____

Location

Sex ___________

Divorced 

_______________________________________________

Site/Route

Zip:_________ E-Mail:______________________

Phone # (H) _______________________ (W) ______________________ (cell) __________________ Does this person have a key to your home? Yes  No  Do we have your permission to discuss medical or other concerns with this person? Yes  No 

2 Do you currently have a primary care physician? Yes  No  Physician Name: ____________________________________ Phone Number______________________ Street: ________________________ City:_____________________ State:________ Zip____________ When is the last time you saw your doctor? ____________________________________________________ Do you need/want a referral to a doctor and associated medical personnel that would see you in your home instead of in their office? Yes No Do you have a designated legal guardian/proxy or power of attorney? Yes No Name: ______________________________________ Phone Number: _______________________ Address: ___________________________________________________________________________ Relationship: ___________________________ Details: ____________________________________________________________________________ Do you have a social worker or case manager assisting you from another agency? Yes No Name: ______________________________________ Phone Number: _______________________ Agency: ___________________________________________________________________________ Address: ___________________________________________________________________________ Details: ____________________________________________________________________________

How did you hear about Meals on Wheels of Central Maryland?_________________________________ REFERRED BY: Name: _____________________Agency: ___________________Phone: ___________________

MEDICAL PROBLEMS ARTHRITIS HEART DISEASE STROKE SEIZURES CONFUSION DEPRESSION ALCOHOLISM INCONTINENCE AMPUTEE DIALYSIS

Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No 

HIGH BLOOD PRESSURE LUNG/PULMONARY DISEASE DIABETES RECENT SURGERY CANCER type:___________________ ALZHEIMERS/DEMENTIA PARKINSON'S DISEASE HISTORY OF MENTAL ILLNESS CATARACT/GLAUCOMA INCONTINENCE

Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No 

USE ELECTRICALLY POWERED MEDICAL DEVICE (That would cause serious problems if lost due to an electrical outage) Yes  No  USE OXYGEN Yes  No  Other Medical Problems: ________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

VISION: HEARING: MOBILITY:

Good  Partial  None Good  Partial  None Good  Partial  None

Glasses Yes  No  ____________________ Hearing Aide Yes  No  ____________________ Cane Wheelchair  Walker  Non-ambulatory 

3 Will you have difficulty answering the door? Yes  No  If yes, specify what type of difficulty. _____________________________________________________. Will you need help with your meals? (opening packages, cutting food, etc.) Yes No . What type of help will you need? ________________________________________________________ Do you have access to a refrigerator? Yes  No 

Do you feel socially isolated?

Yes No

If the following services were available would you be interested in having: A Companion (2 visits per month)

Yes  No 

A Volunteer Grocery Shopper

Yes  No 

A Phone Pal

Yes  No 

Would you like to be a Phone Pal?

Yes  No 

Would you be interested in volunteering to be a route chairperson from your home? Yes  No  (Route chair people call volunteers to remind them of their days of service, and thank them for volunteering.) SUPPORTIVE SERVICES NEEDED (Referrals requested): ____________________________________________________________________________________ ____________________________________________________________________________________ OTHER NEEDS:______________________________________________________________________ OTHER AGENCIES CURRENTLY HELPING YOU: Agency:______________________________________________ Phone:________________________ Worker Name:_______________________________ Frequency:_______________________________ Type of help: _________________________________________________________________________ Agency:______________________________________________ Phone:________________________ Worker Name:_______________________________ Frequency:_______________________________ Type of help: _________________________________________________________________________ Does Meals on Wheels of Central MD have your permission to give your name and contact information to other organizations that we believe may be able to help you locate or access additional benefits you may qualify for? Yes  No 

4 Does Meals on Wheels of Central MD have your permission to disclose information to other agencies that may be able to assist you in order to facilitate their provision of services to you? Yes  No  Meal Delivery: Special Requests:

Kosher food 

Days Requested:

Monday 

No Pork 

Tuesday 

No Fish 

Wednesday 

Texture Modified  Thursday 

Friday 

Weekend 

Frozen meals are delivered prior to holidays to eat on holidays when there is no meal delivery * I wish to receive frozen meals to eat on holidays when Meals on Wheels does not have delivery service  * I do not wish to receive frozen meals to eat on holidays when Meals on Wheels does not have delivery service  Once a week delivery preferred if available



(Note: Not yet available)

This is anticipated to be a temporary need following surgery, etc. 

How should your MOWCM volunteer enter your home? (knock, key, etc.) ____________________________________________________________________________________ Do you have a door which faces the outside so a volunteer can knock on it? Yes  No 

If you do not have a door which faces the outside (as with apartments in apartment buildings,) is there an intercom on the building? Yes  No  Note: If you do not have a door which faces the outside, and do not have an intercom, you must provide MOWCM with a key to the building.

Are you providing a key to your apartment building? Yes  No  Are you providing a key to your house or individual apartment? Yes  No 

Why do you need Meals on Wheels home delivered meals? (Check all that apply.)



I live alone and am physically/mentally unable to prepare my own food.



I live alone and am physically/mentally unable to shop for myself.



Someone else lives with me, but he/she is also unable to prepare meals.



Someone else lives with me, but he/she is away during the day, working/at school/etc.



Someone else lives with me, but he/she is unable to prepare meals for me for another reason.



I am unable to afford sufficient food

Intake reviewed by/assistance provided by (MOWCM staff person): ________________________

DATE:_________

5 MONTHLY INCOME AND EXPENSES: (Alternatively pay full amount, no financial disclosure required.  ) INCOME Social Security SSI Pension Other Dividends Interest Food Stamps

CLIENT

SPOUSE

EXPENSES

CLIENT

SPOUSE

$ $ $ $ $

$ $ $ $ $

Housing Gas/Oil (Monthly Average) Electric (Monthly Average) Water (Monthly Average) Taxes (include all taxes) Insurances (Include all

$ $ $ $ $

$ $ $ $ $

$

$

insurances EXCEPT auto)

$

$

$

$

Phone (Monthly Average) Transportation Medicines (Monthly Average) Medical (Monthly Average) Personal Medical Care

$ $ $ $

$ $ $ $

$ $

$ $

$146

$116

$

$

(home nursing care, seeing eye dog, Depends, etc.)

Food (Staff will fill in) Misc. (Clothing, haircuts, Housekeeping Supplies, newspapers, gifts, etc. Other (Specify) _________ ________________________ (Staff will fill in)

Total Income

(Staff will fill in)

$

$

Total Expenses

Total Combined Income

Total Combined Expenses $

$

Total Disposable income:

Fee Basis:

Number of people in family supported by this amount Monthly Fee

$

Pledge Amount

$

Person Responsible for Fee: Name ___________________ Address ___________________________________ Phone: (H) ________________ (W) ____________________ (C) __________________________________

If paying with Food Stamps: Name on Card __________________________________ EBT Number ___________________________________ Day of Month Funds available _____________________ Have you applied for: Food Stamps? Yes No Note: Meals on Wheels accepts food stamps as payment for meals and can help with the application process.

Are there children or disabled adults present in your household, other than the ones reported on the above chart? Yes No

6 Financial Instructions: 1) Use actual figures for rent or mortgage payment. If client lives in a house with a paid of mortgage, use $100/month for cost of repairs and maintenance of house. 2) Use actual cost of Gas and or Oil averaged for the year. If figures appear too high, refer client to Energy Assistance & Weatherization programs; and ask for proof of amount paid. (Get appropriate phone # from Community Resource Guide.) 3) Use actual cost of electric averaged for the year. 4) Use actual cost of water averaged for the year. 5) Include all taxes: real estate, federal/state/municipal, school, per capita, etc. 6) Use actual cost of phone, up to a maximum of $65. (Suggest client looks into one of the free/discounted wireless or landline services.) 7) Transportation: Allowable expenses include bus, limited taxi, medical transport, payments to neighbors to drive places, etc. Use actual cost to a maximum of $77.40/month (representing the cost of using MTA Access II Taxi service 3 times per week to get to and from doctors appointments, senior centers, worship services, etc.) 8) Average monthly cost of all prescription and non-prescription medicines, durable medical equipment, glasses, etc. 9) Average monthly medical expenses including premiums, co-pays, doctor bills, dental bills, etc. 10) Personal Medical Care: Actual cost of personal care attendant, seeing eye dog, etc. Note: Use IRS chart for “scheduled expenses.” 11) Food = $3.25 X number of meals not provided by Meals on Wheels of Central Maryland, Inc. (i.e. If client receives MOWCM 5 times/week, with 4.3 weeks in a month, then allow $153.72 for food expenses other than MOWCM food. If client receives MOWCM 3 times/week, with 4.3 weeks in a month, then allow $209.62 for food expenses other than MOWCM food. If client receives MOWCM 2 times/week, with 4.3 weeks in a month, then allow $237.57 for food expenses other than MOWCM food. Finally, if client receives MOWCM 6 times/week, (that is 5 days a week plus weekend supplement) with 4.3 weeks in a month, then allow $125.77 for food expenses other than MOWCM food. 12) If there is a major additional expense not list anywhere else, specify what it is in “Other” For Dependent Children’s expenses: Children under 10 13) Food costs should be counted as half those of an adult 14) Clothing, haircuts, housekeeping supplies, newspapers, gifts, etc. will include school supplies, etc. and should be the same as for a spouse Children over 10 15) Food costs should be counted the same as client’s or spouse’s 16) Clothing, haircuts, housekeeping supplies, newspapers, gifts, etc. will include school supplies, etc. and should be the same as for a spouse Important Notes: 1) Clients who do not have phones must apply for free/discounted phone service, and give us an alternative number in the meantime. 2) While Social Security numbers are not needed to sign up for service, they are required for government subsidy programs. 3) Individuals who choose not to cooperate with subsidy requirements (allowing a case worker into their home, etc., will be charged the full, unsubsidized cost of the meal.)