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Henderson Services
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Application For Services

Application for Services

For the Adult-Day Program, this form is utilized to determine funding only, and not to apply for the program. If you would like to learn more about the application process, please call: (828) 697-7070 for Henderson County or (828) 277-3399 for Buncombe County.

PROGRAM TYPE

Which program type are you interested in? Check all that apply.

Meals on Wheels

Community Dining

Adult Day (Buncombe County)

Adult Day (Henderson County)

Caregiver Services

Information

CLIENT INFORMATION

First Name

Last Name

Address (Street)

Apartment Number and Apartment Name

City

State

Zip Code

Client Telephone Number

Client Secondary Telephone Number

Client Email Address

Client birthdate

Gender

Race

Primary Language

Primary Language

Language

MARITAL STATUS

What is your current marital status?

HOUSEHOLD INFORMATION

Do you have pets in the home?

Yes

No

Dog

Yes

No

Cat

Yes

No

Are you a veteran or spouse of a veteran?

Yes

No

Spouse of veteran

List other agencies that are serving the client

REFERRAL INFORMATION

Referred By

Referral Agency

Telephone Number

Email

Client Relationship

EMERGENCY CONTACT INFO

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Primary Telephone Number

Emergency Contact Primary Email Address

Secondary Emergency Contact Name

Secondary Emergency Contact Relationship

Secondary Emergency Contact Primary Telephone Number

Secondary Emergency Contact Primary Email Address

List mental and physical disabilities

NUTRITIONAL HEALTH SCREENING

Do you have an illness or condition that made you change the kind or amount of food you eat?

How many meals do you eat per day?

How many servings daily of fruit ?

How many servings daily of vegetables?

How many servings of milk and dairy products?

How many alcoholic beverages do you have daily?

Do you have tooth or mouth problems that make it hard for you to eat?

Do you always have enough money or food stamps to buy the food you need?

How many meals do you eat alone daily?

How many prescribed drugs?

How many over the counter drugs?

Have you lost 10 pounds in the past six months without trying?

Have you gained 10 pounds in the past six months without trying?

CAN YOU PERFORM THESE TASKS WITHOUT HELP?

Prepare Meals

Yes

No

Personal shopping

Yes

No

Manage Medications

Yes

No

Manage Money

Yes

No

Use Telephone

Yes

No

Use Transportation (including public)

Yes

No

Housekeeping

Yes

No

Laundry

Yes

No

Feed yourself

Yes

No

Get dressed

Yes

No

Bathe yourself

Yes

No

Use the toilet

Yes

No

Get in and out of bed

Yes

No

Do you have self control over your bowels & bladder?

Yes

No

Who helps you with the items above which you are unable to perform alone?

Within the past 12 months, did you worry that your food would run out before you received more money to buy more?

Yes

No

Within the past 12 months, did the food you bought just not last and you didn't have money to get more?

Yes

No

Comments

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We can help you navigate the journey.

Call Our HelplineCall (828) 692-4203

Address: 105 King Creek Blvd, Hendersonville, NC 28792 Phone: 828-692-4203 Email: connect@mapnc.org

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