Group Orientation | The Disabled Resources Center of Long Beach

Group Orientations

Every Thursday at 9:00am • Group Intake for all New Consumers to Disabled Resources Center, Inc.

Group Intake is a FREE information presentation available to all persons interested in becoming a consumer with Disabled Resources Center, Inc.(DRC). Come to learn what DRC 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 an individual meeting will be scheduled immediately following the intake with 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:

Today's Date

xx/xx/xxxx
First Name

Please insert your first name here.
Last Name

Please insert your last name here.
Phone Number

Please use parenthesis and hyphens and include area code (555) 555-5555.
Email Address

Please insert your email address here.
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Date of Birth

xxxx
Last 4 of Social Security Number

xxxx
Ethnicity

Please select one.
Sex

Please select one.
Please indicate service(s) requested by order of need (1 for primary, 2 for secondary, etc. List up to 4):
Advocacy
A.T.
PA Referral
Employment
Benefits
Community Advocacy
Homeless
Veteran
Housing
I&R
ILS
Transportation
Peer Support
Transitional Funding
How did you hear about us?
Marital Status

Please select one.
If other, please state:
# in Household

How many people live in your home?
Are you the head of Household? Yes No
# of Children

How many children under 18 years old live in your home?
Emergency Information

Who should we contact in case of an emergency?
Source of Income
Private

Enter Dollar Amount ($0.00)
SSI

Enter Dollar Amount ($0.00)
SSDI

Enter Dollar Amount ($0.00)
VA

Enter Dollar Amount ($0.00)
Other

Enter Dollar Amount ($0.00)
Medical Information: Medi-Cal Medicare SSA Other Insurance
Notes

Let us know anything else that we might need to know!

Or click here to download a printable form

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

Source of Income