USVI Public Records

Document text

GOVERNMENT OF THE VIRGIN ISLANDS Virgin Islands Department of Human Services MEALS ON WHEELS APPLICATION Using a pen, please complete the following information as completely as possible. LAST NAME: ______________________ FIRST NAME: __________________________ M.I. ____ Date of Birth: ______________________ Marital Status: ____________ Race:_________ Sex:____ Physical Address: __________________________________________________________________ Telephone: (Home) ___________________________ (Cellular)______________________________ In case of emergency, contact: Name: _____________________________________ Telephone: ___________________________ Physical Address: _________________________________________________________________ IF YOU HAVE ANY QUESTIONS, PLEASE CALL: 340-725-6265 or - 340-642-6289 The completed form may also be emailed to: alice.henry@dhs.vi.gov NOTE: Please fill out application in entirety. Failure to do so may delay the application process. GOVERNMENT OF THE VIRGIN ISLANDS Virgin Islands Department of Human Services PHYSICAL/HEALTHCARE PROVIDER MEDICAL SUMMARY IMPORTANT! Briefly, but concisely, summarize the need for this individual to receive home delivered meals. Include specific limitations as well as the length of time meals will be needed. Attach supporting documentation as needed, A sentence like “This person needs Meals on Wheels” or something similar is not acceptable and may delay the application process. NAME OF APPLICANT: ____________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Use of Hands Normal Limited Disabled Use of legs/feet Normal Limited Disabled Uses a Walker Uses a Wheelchair Speech/Use of Mouth Normal Difficulty Chewing Difficulty Swallowing Use of Eyes Normal Limited Blind (Partial / Total) Mental Status Normal Limited - Explain: ____________________________ Any History of the Following? (Circle all that apply) CVA/Stroke Heart Disease Diabetes Hypertension Alzheimer’s/Dementia Kidney Disease/Dialysis Cancer Other: ____________________________________________________________________________ NAME of Health Care Professional (Print) SIGNATURE/DATE Phone Number (Health Care Professional): ______________________________________ Physical Limitations (please answer all questions): Dietary Needs (Circle all that apply) : Is the applicant bed-bound Yes No Is the applicant able to heat up food on the stove or in microwave? Yes No Does the applicant live alone ? ______ If not, how many able-bodied individuals live in the household with the applicant? ________ How many family members/friends are available to help with the applicant? ________ Can/does the individual drive? Yes No Circle Days that Meals are Needed: M – F Sat Sun Holidays Referral Needs: __________________________________________________________________ Approved: Y N Reason (if no): _____________________________________________________________________ Interviewed By (Print name) : ____________________________________________ Signature: _______________________ Title: __________________Date:__________ By signing below, I agree that I have received the Participant Agreement Form and agree to follow all the guidelines for participation in the Meals on Wheels Program: Client Signature: _________________________________________Date: _________ Date: _______________ Reason: _____________________________________________ ___________________________________________________________________________ Signature: _____________________________Title:__________________ Date:_________ Termination: FOR DEPARTMENT OF HUMAN SERVICES STAFF ONLY *DO NOT COMPLETE* Staff’s Assessment: