Referral Form

We serve people of ALL ages and ALL incomes who are homebound and unable to prepare their own meals. We serve people with temporary needs (following surgery, severe illness, during chemotherapy, etc.) and long-term needs, too. Need more details? Visit our Meal Delivery, Feeding Friends, or Nutritional Drink pages first!

Are you a medical professional referring a patient? Please complete our Medical Referral Form to initiate meal delivery!

Ready to get a meal for a friend, family member, neighbor, or even yourself? Please complete this form ONLY for individuals living in the following zip codes: 29464294662949229451, and 29482. If the potential recipient does not reside in one of those zip codes, please call Trident United Way’s Hotline by dialing 2-1-1 to find a meal delivery program that delivers to their area.

  • Prospective Meal Recipient's Information

  • MM slash DD slash YYYY
  • Referrer Information

    If you are a family member, neighbor, friend, or other individual completing this form on behalf of someone else, please complete this section. If you are referring yourself for meals, you may skip to the medical details section.
  • Who should we contact to complete the interview process before the first meal delivery? (Choose one)
  • Medical Details

  • Please choose the option best describing the anticipated duration of meal delivery service.
  • Please provide any additional notes or details on this prospective recipient's condition or status.
  • This field is for validation purposes and should be left unchanged.