Meals On Wheels New Client Form - Interfaith Ministries for Greater Houston

Thank you for your interest in Meals on Wheels. Please complete the questionnaire below. A member of the Meals on Wheels new client intake team will contact you. If you have any questions, please call (713) 533-4978.

What is your zip code?*
Are you over 60 years of age and homebound?*
Are you unable to drive?*
Do you have trouble preparing your meals?*
If you answered yes to all of the above, proceed below.
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Date of Birth*
MM slash DD slash YYYY
Phone number*
Emergency contact name*
First Last
Emergency contact phone*
Do you have a health care provider from the state from 9am to 1pm helping you with cooking?*