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Meeting ID: 896 9937 8901
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Meeting ID: 896 9937 8901
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Group Intake is a FREE information presentation available to all persons interested in becoming a consumer with Disabled Resources Center (DRC). Come to learn what DRC programs and services you may be eligible for. If you are a current consumer or have attended the group intake within the past 3 years there is no need to attend group intake, simply call in and set an appointment. Intake will last approximately 45 minutes and when possible, an individual meeting will be scheduled immediately following the intake with an appropriate staff member. Please refrain from wearing scented products to this and all activities at DRC.

Please fill out the new consumer intake form below:

Name
First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Birthday*
Month
Day
Year
Last 4 SSN*
Ethnicity:
Gender Identify As:
Sexual Orientation or Sexual Identity:
Living Situation:
Veteran Status:
Registered Voter?
Accessible?
Are you a CalFresh recipient?
Do you have a caregiver?
Do you have adequate access to food?
In-Home Supportive Services Recipient?
Are you or do you feel at risk for institutionalization?
Does anyone at home make you uncomfortable, feel afraid, or threaten you?
Are you kept isolated from friends or relatives?
Do you feel someone is taking your money without approval?
Please indicate service(s) requested by order of need (1 for primary, 2 for secondary, etc. List up to 4) with the dropdowns below:
Primary:
Secondary:
Third:
Fourth:
Please indicate primary (PD) and secondary (SD) disability where applicable with the dropdown below:
Primary:
Secondary:
How did you hear about us?
Marital Status
Are you the Head of Household?
# in Household
# of Children in household
Emergency Information
Income Source:
Employment/Private
SSI Benefits
SSDI Benefits
Cal-Fresh Program
VA Benefits
Pension/Retirement
SSA Retirement
State Disability
Welfare (Cash-Aids)
Worker's Compensation
Unemployment
Child Support
Family Support
No Income
Insurance Provider
Electronic Signature*
Sign and Date

Join Zoom Meeting
https://us02web.zoom.us/j/89699378901

Please fill out the new consumer intake form below:

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

Please indicate primary (PD) and secondary (SD) disability where applicable with the dropdown below:

Income Source:

Contact

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Get Started

Join Zoom Meeting https://us02web.zoom.us/j/89699378901

Please fill out the new consumer intake form below:

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

Please indicate primary (PD) and secondary (SD) disability where applicable with the dropdown below:

Income Source:

Contact

Quick Links

Stay Connected

Follow us

Join Zoom Meeting
https://us02web.zoom.us/j/89699378901