Client Intake & Service Request Form

Page 1

This form is exclusively for new or existing clients of DAC. Please do not fill this form out if you are not seeking services from Deaf Action Center. If you are interested in volunteering, please check the volunteer section of our website. If you have non-client service related questions, please email info.assist@dactexas.org or call (214) 521-0407. Thank you!

Contact Details

First Name

Last Name

Birthdate

Your primary language

Street Address (Including Apartment #)

City

State

Zip

County

Home Phone

Mobile Phone

Work Phone

Video Phone

Text ONLY Phone

Preferred Communication:

Phone/VP	Text Only
Email	Would you like to receive the DAC Newsletter?

Emergency Contact

First Name

Last Name

Phone

Relationship

Services Requested

How can we help?

Please select the primary reason you are reaching out today:

Please select the secondary reason you are reaching out today (If Applicable)

In a few words, please describe your request:

Page 2

Income & Benefits

In order to receive our free services, we request that you provide as much information as possible so we may report on who we serve.

Employment Status

Household Income Range

Do you live alone?

YesNo

Total number of household members including yourself

Are you Enrolled In:

Medicare/MedicaidOther Benefits (SNAP, WIC, Food Stamps, etc)

MEDICARE #

MEDICAID #

Your Income

Job:

VA:

SSI/SSDI:

Other Income:

Other Household Income

Job:

VA:

SSI/SSDI:

Other Income: