NSW Meals on Wheels - Client Referrals

Client Referrals

If you would like to make a referral for yourself or someone else, you can do so in one of three ways.

Option 1:

Call our friendly staff on (02) 4274 4311 and we will be more than happy to step you through our intake process.

Option 2:

Download the Client Referral Form , complete the form and return email to admin@pkmow.org.au

or post to

P.O. Box 224
PORT KEMBLA NSW 2505

Option 3:

Fill out the form below and click “Submit”. Please include as much information as possible.

Fields marked with an * are required.

First Name*:

Last Name*:

Street Address*:

Suburb*:

Postcode*:

Phone:

First Name:

Last Name:

Carer:

Does the client need assistance to negotiate?:

If yes, please specify:

Reason for requiring service:

Dietary Requirements:

Hot
Frozen

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

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

First Name*:

Last Name*:

Phone Number*:

Email:

Organisation*:

Title / Department*: