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Online Intake Form

Meals on Wheels West serves people of all ages and all incomes. Meals are low cost, and you may qualify for subsidies.

Enroll online or call for delivery to your door: (310) 394-5133 ext. 1

You will need to call to follow up with your online application after submitting. Call (310) 394-5133, extension 1.

Enroll Now

Personal Information
Applicant Name*
First Last
Phone*
Email*
Home Address*
Street Address Address Line 2 City State ZIP Code
Do you live alone?*
- Yes
- No
Gender*
- Male
- Female
- Transgender
- Non-binary/non-comforming
- Prefer not to respond
Birth Date*
MM slash DD slash YYYY
Physical Condition
Why 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
- African American
- White
- Other
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 Information
Monthly Income*
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 Information
Name of Physician
Physician Phone
Physician Fax
Physician Address
Street Address Address Line 2 City State ZIP Code
Emergency Contact
Name of Relative/Friend*
Relationship*
Relative/Friend Phone*
Relative/Friend Address*
Street Address Address Line 2 City State ZIP Code
Second Emergency Contact (Optional)
Name of Relative/Friend
Relationship
Relative/Friend Phone
Relative/Friend Address
Street Address Address Line 2 City State ZIP Code
Services Requested
Diet*
- Regular
- Vegetarian
- Renal
- Low K
Special instructions
Additional Information
Comments
Delivery Instructions
Phone
This field is for validation purposes and should be left unchanged.

You will need to call to follow up with your online application after submitting. Call (310) 394-5133, extension 1.

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Serving LA Coastal Communities Since 1974

1823-A Michigan Avenue, Santa Monica, CA 90404
(310) 394-5133
info@mealsonwheelswest.org

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