Please fill out the below form to learn how to get services from Meals on Wheels and Grace Place Alzheimer's Activity Centers. You can use this form to refer someone, or you can fill it out on your own behalf too! Name * Email * Phone Number * How did you hear about us? * Billboard Coworker Facebook Family or Friend H-E-B Magazine Meals on Wheels Truck Newspaper Physician Radio Street Banner Television United Way WellMed Web Search Other Other Who are you referring for services? * Myself Someone else Name of person you are referring * What is your relation to person you are referring? Phone number for person you are referring * Date of Birth (MM/DD/YYYY) * Street Address * City * State * Zip Code * What services are needed? * Meals on Wheels Grace Place For Meals on Wheels please indicate the following (May choose more than one): * The person is 60 years of age or older The person is unable to drive The person is unable to prepare meals The person does not have a provider The person has: * Medicaid Medicare Both Unknown You selected Meals on Wheels, please indicate the following (May choose more than one): * I am 60 years of age or older I am unable to drive I am unable to prepare meals I do not have a caregiver I have: * Medicaid Medicare Both Unknown Was this person recently released from the hospital? * Yes No Were you recently released from the hospital? * Yes No If so, when? Reason for hospitalization? When is the best time to contact this person? * Morning Midday Afternoon Anytime When is the best time to contact you? * Morning Midday Afternoon Anytime What is the best way to contact this person? * By Phone Home visit Via Family What is the best way to contact you? * By Phone Home visit Via Family Family Member * Family Member Phone Number * Family Member Relation * Has a doctor or other health care professional told you that you suffer from memory loss, cognitive impairment, any type of dementia, or Alzheimer’s disease? Yes No Additional Information? CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.