Client Intake & Service Request Form

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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












Emergency Contact





Services Requested
How can we help? Please choose all that apply.


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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.





Your Income
Other Household Income

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Demographic Information






Referral Details