Pickens County
 Meals on Wheels

Serving the elderly of Pickens County       

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Pickens County Meals On Wheels Referral Application

Anyone who is 65 and older and is unable to prepare nutritious meals and who has no one to help them with meal preparation and lives in Pickens County  is eligible to receive meals.   If you meet these requirements, you may fill out the form below and press the Send button.  Someone will be in touch with you.

Special NOTE: press the tab button to move from field to field

 

Your Name:
Email Address:
Referral Date:
Phone (daytime)
Applicant's Name:
Street Address:
Phone:
Mailing Address
Directions to Home:
What Door do we use:
Working Smoke Alarms:	Yes:   No:
Next of Kin:
(Do not use Spouse as next of kin)
Relationship:
Day Phone:
Evening Phone:
Address:
Emergency Contact # 2
Relationship:
Phone:
Church Name:
Requesting Service:	Permanent:    Temporary:
Are There Loaded Guns in the House?  If So Where?	Yes:   No:
General Information:
Living Alone?	Yes:   No:
At least 1 visitor per day?	Yes:   No:
Daily phone call?	Yes:   No:
Lifeline?	Yes:   No:
Hospice?	Yes:   No:
Do they drive?	Yes:   No:
Do their own shopping?	Yes:   No:
How are they currently getting meals?
Do they have good family/friend support  (Who)?	Yes:   No:
Do they have a Refrigerator?	Yes:   No:
Separate Freezer?	Yes:   No:
Do they have & can use:	Stove:          Oven:       Microwave:
Do they have sufficient income to purchase their groceries?	Yes:   No:
Food Stamps?	Yes:   No:
Do they have pets?	Yes:   No:
Does anyone assist them with Daily Living Activities?	Yes:   No:
Social Worker?	Yes:   No:
Home Information:	Rent:: Own: Mobile: Frame:  Brick:
How long have they resided there?
Do they have:	Heat:       A/C:     Electricity:      Phone:    Running Water:   Hot Water:
Do they have someone to do minor repairs & help out with problems?	Yes:   No:
Applicant:
First Name:
Age:
Date of Birth:
Primary Physician?
How is their Vision?
How is their Hearing?
How is their Emotional Status?
Any confusion or dementia?	Yes:   No:
Do they use a	Cane:   Walker:  Wheelchair:  Bedfast:
Are they Diabetic:	Yes:   No:
Diagnosis:
Overall Condition:
Spouse's:
First Name:
Age:
Date of Birth:
Primary Physician?
How is their Vision?
How is their Hearing?
How is their Emotional Status?
Any confusion or dementia?	Yes:   No:
Do they use a	Cane:   Walker:  Wheelchair:  Bedfast:
Are they Diabetic:	Yes:   No:
Diagnosis:
Overall Condition:
Once finished, press the Send Button (below).