Wellness Check request

2. Do you yourself, or a family member, friend, or acquaintance need someone to check in? Any person living in Menlo Park who needs to be checked on during this pandemic is a candidate for the City of Menlo Park's expanded wellness check program.
   
   The program is available citywide to any community member who may benefit from a weekly call. The program is ideal for community members who may live alone, have special needs and/or older adults and community members experiencing food or housing insecurity. Community members who would like to refer a vulnerable neighbor, or family members wanting to sign up a loved one, can request a wellness check with the form below. City staff, who are background checked and supervised, will be able to connect those referred with various City, county, and nonprofit resources available to them and will check on them weekly until the stay-at-home order is lifted.
   
   This is not a replacement for 911 calls. If it's an emergency, CALL 911 immediately.
   Services are intended ONLY for those within the City of Menlo Park jurisdiction (city limits).
   
   Checks will be conducted 8 a.m. to 5 p.m. Monday through Friday.
3. 
7. Wellness Check Participant
   This is the person staff will contact for the wellness check.
9. First name
10. Last name
12. Phone number
13. Email (optional)
15. Address1
17. Address2
19. City
20. State
21. Zip
23. Preferred language for communication
27. Referrer contact information
    Do not fill this section out if you are registering yourself for a wellness check.
29. What is your relationship to the person being referred?
31. First name
32. Last name
34. Phone number
35. Email (optional)
37. Address1
39. Address2
41. City
42. State
43. Zip
45. If you’re having trouble with the wellness check request form or have any questions, please call 650-330-2220 and leave a message. We will get back to you as soon as possible.
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field