Referral | Meals on Wheels San Antonio

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!

Meals on Wheels Services include: Meal delivery, AniMeals, Friendly Visitor, Comfy Casas, and more.

Comfy Casas is supported by a grant from the Texas Veterans Commission Fund for Veterans’ Assistance. The Fund for Veterans’ Assistance provides grants to organizations serving veterans and their families. For more information, visit www.TVC.Texas.gov.

Name

Phone Number

How did you hear about us?

Who are you referring for services?

Other

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

Does this person live in one of the following cities?

Alamo Heights, Balcones Heights, Elmendorf, Grey Forest, Helotes, Kirby, Leon Valley, Live Oak, Schertz, Somerset, Universal City, or Von Ormy

Do you live in one of the following cities?

Alamo Heights, Balcones Heights, Elmendorf, Grey Forest, Helotes, Kirby, Leon Valley, Live Oak, Schertz, Somerset, Universal City, or Von Ormy

Which City?

What services are needed?

You selected Meals on Wheels, please indicate the following (May choose more than one):

For Meals on Wheels please indicate the following (May choose more than one):

Is the person you are referring a Veteran?

The person has:

Are you a Veteran?

I have:

Were you recently released from the hospital?

Was this person recently released from the hospital?

If so, when?

Reason for hospitalization?

When is the best time to contact you?

What is the best way to contact you?

When is the best time to contact this person?

What is the best way to contact this person?

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?

Additional Information?

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