Community Connections Client Intake Form Enroll online or call for assistance: Neeley Pinkney, Health and Wellness Coordinator, (310) 394-5133, extension 7. Enroll Now Personal InformationApplicant Name* First Last Phone*Email* Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of Residence* Apartment House Hotel Does the individual* Rent Own Unknown Do you live alone?* Yes No Gender* Male Female Non-Binary Decline to state Birth Date* MM slash DD slash YYYY Age* Height Weight Physical ConditionWhy is service being requested ?*Disability Visually Impaired Hearing Impaired Physically Impaired Mentally Impaired Marital Status* Married Single (Never Married) Widowed Domestic Partner Divorced Separated Client Race* Hispanic/Latino Asian Black White Native American or Alaskan Native Native Hawaiian or other Pacific Islander Other (specify below) Decline to state Specify Race Primary Language Spoken* Translation needed?* Yes No Do you have pets?* Yes No If yes, what and how many? Have you ever been homeless?* Yes No Do you identify as LGBT? Yes No Are you a veteran or a spouse of a veteran? Yes, Veteran Yes, Spouse No Financial/Insurance InformationMonthly Income* Rent* Are you currently receiving SSI/SSP?* Yes No Do you have Health Insurance?* Yes No Please enter the name of your insurance provider* Are you enrolled in Medi-Cal?* Yes No Are you enrolled in Medicare?* Yes No Do you have a case manager?* Yes No Case Manager Name* First Last Case Manager Phone*Case Manager Email* Do you receive In-Home Supportive Services?* Yes No Is your personal income below $13,590 per year?* Yes No How did you hear about Meals on Wheels West? Physician InformationName of Physician Physician PhonePhysician FaxPhysician Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactName of Relative/Friend* Relationship* Relative/Friend Phone*Relative/Friend Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Second Emergency Contact (Optional)Name of Relative/Friend Relationship Relative/Friend PhoneRelative/Friend Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Additional InformationCommentsCommentsThis field is for validation purposes and should be left unchanged.
