Client Referral Form
Please complete this form to refer a potential client to the Meals On Wheels Collin County food services program. Referrals for home delivered meal service are screened by phone via a caseworker who will then complete a home visit to determine eligibility.

Eligibility requirements:
• 60 YEARS OF AGE OR OLDER; OR
• UNDER 60 YEARS OF AGE AND DISABLED
• NO PAID IN-HOME MEAL PROVIDER
• DIFFICULTY SHOPPING OR COOKING
• PRIMARILY HOMEBOUND
• RESIDENT OF COLLIN COUNTY

Please allow 72 business hours for initial contact to be made. Our office is open Monday-Friday from 7:30am-4pm CST (excluding holidays). Once all documentation has been processed, services will commence within 1 business day of approval.

Email address *
Client's Name *
Your answer
Client's Address *
Please include city and zip code
Your answer
Client's Phone Number *
Your answer
Client's Date of Birth *
MM
/
DD
/
YYYY
Is the client *
Please check all that apply
Required
Is the client aware of this referral?
Please check all that apply
Referring Contact Name *
Your answer
Relationship to client
Your answer
Referring Contact Phone Number *
Your answer
Please provide a brief description of client's condition *
Your answer
How did you hear about MOWCC? *
Your answer
Emergency Contact Name and Phone Number
Please provide an emergency contact for the client in case of meal delivery delays and other needs
Your answer
Submit
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