Disabled Resources Center, Inc

Disabled Resources Center, Inc.

Group Intake Demographics Form

PLEASE PRINT_____ / _____ / ______

Today’s Date

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______

First Name
______

Last Name
( _____ ) _____ - ______

Phone

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______

Address 1
______

City

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State: _____
Zip Code: ______
County: _____

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Email ______

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Date of Birth: _____ / _____ / ______

Social Security Number: XXX - XX - ______

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Ethnicity:

Asian/Pacific Islander
AmericanIndian/Alaskan

African American

Caucasian
Hispanic

Other

Unknown
Female

Male

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Living Situation:

Independent
Institution

Dependent

w/Family-Friends

Assisted Living
Homeless

Unknown

Other ______

Accessible?

Y

N

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Please indicate service(s) requested by order of need (1 for primary, 2 for secondary, etc. List up to 4):

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1234 Advocacy

1234 A.T.

1234 PA Referral

1234 Employment
1234 Benefits

1234 Community Advocacy

1234 Homeless

1234 Veteran
1234 Housing

1234 I&R

1234 ILS

1234Transportation
1234 Peer Support

1234 Transitional Funding

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How did you hear about us? ______

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Marital Status:
Married

Divorced
Separated

Widowed
Other______

Single

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# in Household_____

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# in Household Are yAre you the Head of Household? # of Children in______

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Emergency Information: ______

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Source of Income:

Private: $_____
SSI: $_____
SSDI: $_____
VA: $_____
Other: $_____

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Medical Information:

Medi-Cal

Medicare SSA

Other Insurance

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Notes: ______

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