IDignity Inc. Client Service Request Form
Please fill out this form so that we have record of your needs and can appropriately prepare for your appointment.
Submitter Information
IDignity Location
Orlando
Seminole
Volusia
Are you in need of services or requesting services for somebody else?
I'm in need of services
I'm requesting services for somebody else
Do you have a case manager or advocate that you want us to reach out to?
Yes
No
Advocate Contact Info
Agency Name
Advocate Name
First Name
Last Name
Advocate Email Address
Advocate Phone Number
Client Information
Client Name
First Name
Middle Name
Last Name
Last Name at Birth
Suffix
Date of Birth
MM/DD/YYYY
Which of these apply?
Born a US Citizen
Became a US Citizen
Legal Resident
Not a Legal Resident
Where were you born?
Please indicate state of birth if born in the US, or the country you were born in.
Is English your primary language?
Yes
No
Primary Language if other than English
Translation Assistance Needed
I will bring somebody with me to translate
I need translation assistance
No, I also speak English
IDignity cannot promise that translation assistance will be available, but will try to accommodate.
Documents You Need
Documents Needed
Florida Identification or Drivers License
Social Security Card
US Birth Certificate
Other Identification Documents
What other documents are you in need of?
IDignity does not assist with ordering birth certificates from outside of the US or passports.
Have you ever had a Florida ID before?
Yes
No
Unsure
Did your last FL ID / Drivers License have a gold star in the upper right hand corner?
Yes
No
Unsure
Documents You Have
When meeting with IDignity, please bring whatever you have from the list below.
Do you have an ID?
Yes - Valid Florida ID
Yes - Valid ID from another state
Yes - Expired ID
Yes - Photocopy or picture of an ID
No
Unsure
Do you have a original Birth Certificate or immigration document?
Yes - Original / Certified Copy
Yes - Photocopy
Yes - Unsure if it's original or not
No
Don't Know
You can often tell by checking for a raised seal on the document.
Do you have a Social Security Card?
Please select...
Yes - Original
Yes - Photocopy
No
Unsure
What other documents do you have?
Other original record(s)
Photocopy of other record(s)
None of the above
What other record(s)?
Address Information
If you are in need of ID, please also bring proof of address:
Two of the following: Proof of current private residence (lease, mortgage, etc) or bills, employer documentation, financial statements, or mail from government agencies from the last 30 days
Proof of residence at a shelter or transitional program from the last 30 days
Proof of homelessness (letter from agency) from the last 30 days
Letter of residency from person client is living with, as well as 2 proofs of that person's address (they will need to be notarized; IDignity can provide the form for you)
Unhoused and do not have a letter
Anything else to share with IDignity
Follow-up
Client's Email Address
If none, please leave blank
Client's Phone Number
If none, please leave blank
What is the best way for IDignity to connect with you?
Case manager
Client
Please make sure contact information for either case manager or client is submitted, or we will not be able to contact you.
IDignity offers both in-person and phone intakes. Which do you prefer?
In person with an appointment (IDignity will reach out to schedule)
Over the phone (IDignity will reach out to schedule)
I do not want to wait for a scheduled appointment. I will walk in on a Tuesday or Thursday before 9am without an appointment
Client's phone appointment has already been scheduled with their case manager
Please ensure you have enough phone minutes if you choose to do it over the phone; budget around 30-45 minutes.
Date of pre-scheduled appointment
Which case manager booked your appointment?
IDignity will contact you to schedule an appointment in Seminole County. To see the available dates, click
here
.
IDignity will contact you to schedule an appointment in Volusia County. To see the available dates, click
here
.
Based on the results of this survey, IDignity will either reach out to you or the client to schedule a virtual or in-person interview. Thank you for your understanding.
IDignity - Contact Info