Meals On Wheels - Ypsilanti, Michigan

1110 W. Cross St.
Ypsilanti, MI 48197
phone: (734) 487-9669
fax: (734) 482-3868
ymow@tds.net

Make a Referral

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Submit your information electronically using the following form:

Recipient's Name
Birth date
Telephone
Address City, State, ZIP
Nearest Cross Streets

Municipality	City of Ypsilanti Ypsilanti Township Augusta Township Pittsfield Township Superior Township York Township
Ethnic Background	Caucasian African-American Hispanic Native American Asian Other
Marital Status	Married Single Divorced Widowed/Widower
Sex	Male Female
Has client received meals before?	Yes When? No
Is client homebound?	Yes No
Does client live alone?	Yes No
For how long will client need meals?	Short term Long term
Emergency Contact
Relationship
Home Telephone
Work Telephone
2nd Emergency Contact
Relationship
Home Telephone
Work Telephone
Referred By
Telephone
Hospital Referral
Physician
Clinic or Hospital Telephone
Diagnosis/Problems
Funding Source	ANL MIS Medicaid Waiver
If Waiver	MORC AAA CMH
Care Manager
Personal Income
Donation Hot
Donation Cold
Does client handle his/her own business?	Yes No
If No, fill in billing address
Number of hot meals a week	1 2 3 4 5 6
Delivery Days	M T W TH F S
Type of Meal	Regular Diabetic
Number of cold meals a week	1 2 3 4 5 6
Delivery Days	M T W TH F S