If you would like to refer someone to the Northern Illawarra Meals on Wheels service you can do so in one of two ways. If you have any questions about the referral process, please call us on (02) 4285 6126.

Option A:

1. Download the Client Referral Form PDF.

2. Complete the form and email to admin@nimow.com.au

Option B:

Fill out the form below and click “Submit”. Please include as much information as possible. Fields marked with an * are required.

CLIENT REFERRAL FORM

Client details

Name: *
Street Address: *
Suburb: *
Postcode: *
Phone:
Date:
 /  / 

Emergency Contact Details

Name of emergency contact:
Relationship to client:
Carer:

Advocacy

Does the client need assistance to negotiate?:
If yes, please specify:
Reason for requiring service:

Dietary requirements

Dietary requirements:
Other (e.g. diabetic, puree, vegetarian, cultural etc.):

Access to premises

Are there any factors about the home or client that could affect access for staff or volunteers? (e.g. dog, pathways, challenging behaviour):

Source of referral

Name of referrer: *
Phone number: *
Email:
Organisation: *
Title / Department:

Please review and submit the form.