What is the meals on wheels referral form template?
A meal delivery service can only start quickly if the referral has everything in it: who the meals are for, whether they've agreed, what they can eat, which days, how the driver gets in and who to call if they don't answer the door. Missing one of these usually means phone calls back and forth before the first delivery.
This referral form has four pages. The first covers the person — contact details, whether they live alone, whether they know about the referral, why meals are needed and for how long. The second records dietary needs, allergies, swallowing difficulties, dislikes, meals and delivery days. The third gives access instructions, help needed at delivery, the no-answer contact and who pays. The last records the referrer.
Each referral is filed as a PDF in your FileIt vault, so the office and the delivery round work from the same details.
- Best for
- Meals on wheels services, community meal charities, councils and hospital discharge teams
- Filled in by
- A family member, professional or the person themselves
- Time to complete
- About 8 minutes
- Includes
- Consent check, reasons, diet and allergy follow-ups, meals and days, access and key safe, no-answer contact, payment and referrer details
Who uses a meals on wheels referral form?
- A hospital discharge team referring a patient going home
- A daughter arranging meals for a parent who lives alone
- A social worker referring a client after an assessment
- A GP practice referring a patient who isn't eating well
- A charity taking self-referrals from older people
Questions on this meals on wheels referral form
31 questions over 4 pages · includes conditional questions, multiple pages, consent checkbox.
1 The person
- Name of the person needing meals*
- Date of birth
- Their phone*
- Delivery address*
- Do they live alone?*
- Do they know about and agree to this referral?*
- Why not? asked only when it applies
- Why are meals needed?* Recently out of hospital · Limited mobility · Can't cook safely · Memory problems · Recovering from illness · Carer unavailable · Not eating well
- Preferred start date
- For how long? Ongoing · A few weeks · Not sure
2 Meals & diet
- Dietary needs Diabetic · Low salt · Soft or pureed · Vegetarian · Vegan · Halal · Kosher · Gluten-free · Dairy-free · No pork · None
- Any food allergies?*
- Which allergies, and how severe?* asked only when it applies
- Any swallowing difficulties?
- Advised texture, if a speech therapist has given one asked only when it applies
- Foods they dislike
- Meals wanted* Hot lunch · Cold tea or supper · Frozen meals for the week · Breakfast pack
- Delivery days* Monday · Tuesday · Wednesday · Thursday · Friday · Saturday · Sunday
3 Delivery & access
- How should the driver get in?*
- Is there a key safe?
- Pets in the home?
- Help needed at delivery Open packaging · Heat the meal · Put it on a plate · Check they've eaten · None
- If they don't answer the door, who should we call?*
- Who will pay for the meals?* The person themselves · A family member · Funded by council or health · Not sure — please advise
4 About you
- Your name*
- Your role* Self-referral · Family member or friend · Social worker · Hospital discharge team · GP or nurse · Housing officer · Volunteer or charity
- Organisation
- Phone*
- Would you like updates on the referral?
- Consent*
The meals on wheels referral form, page by page
1 The person
The referrer gives the person's name, date of birth, phone and delivery address, and whether they live alone. "Do they know about and agree to this referral?" is required; a no shows a note that agreement is needed and asks why. Reasons for meals range from leaving hospital to memory problems, followed by a preferred start date — blank means as soon as possible — and how long meals are needed.
2 Meals & diet
A checklist covers dietary needs such as diabetic, low salt, soft or pureed, vegetarian, halal, kosher and gluten-free. "Any food allergies?" asks which and how severe on a yes, and swallowing difficulties ask for any advised texture. Dislikes, the meals wanted — hot lunch, cold tea, frozen meals or breakfast — and delivery days complete the page.
3 Delivery & access
"How should the driver get in?" is required, with prompts about doorbells, key safes and how long the person takes to answer. Questions about a key safe, pets and help needed at delivery — opening packaging, heating the meal, checking they've eaten — follow. The referrer names who to call if there's no answer and who will pay.
4 About you
The referrer gives their name, role — from self-referral to hospital discharge team — organisation, phone and email, says whether they'd like updates and confirms the consent statement.
Make the template yours
- Add your prices and payment options in a paragraph on the delivery page
- Edit the meal types and delivery days to match your rounds
- Remove the key safe question if your drivers never use key safes
- Add a postcode check if you only deliver in certain areas
- Notify your coordinator and kitchen by email on every referral
- Route referrals into a folder per delivery round
Tips for a better meals on wheels referral form
- Always confirm with the person themselves before the first delivery
- Pass allergy details to the kitchen in writing, not just verbally
- Agree with drivers what to do if no one answers, and keep the no-answer contact current
- Review referrals marked temporary after a few weeks
- Ask referrers to tell you when someone goes into hospital so deliveries pause
Every response becomes a PDF in your vault
Each referral is saved as a PDF in your FileIt vault and your coordinator is emailed. The referrer can receive a copy of what they sent.
In the Responses table you can see new referrals by delivery day or diet, and export to a CSV to build delivery rounds.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Meals on wheels referral form: frequently asked questions
Is the meals on wheels referral form template free?
Yes. It's a FileIt Forms starter template on every plan.
Can people refer themselves?
Yes. Self-referral is one of the referrer roles.
What if the person hasn't agreed to the referral?
The form shows a note that agreement is needed and asks the referrer why it isn't possible, so your team can follow up.
Does it record allergies?
Yes. Answering yes to the allergy question requires the allergy and how severe it is.
Can we take payment through the form?
No. It records who will pay. Arrange payment separately.
Can hospital teams use it without an account?
Yes. Anyone with the link can refer.