Programs

Group Orientations

Are you interested in becoming a consumer of the Disabled Resources Center (DRC)?

We invite you to learn more about the programs and services offered by DRC and discover which supports you may be eligible for. Our staff is available to answer your questions and guide you through the next steps.

To get started, simply call us to schedule an appointment. You may also complete the form below, and a member of our team will contact you to follow up and assist you further. We look forward to connecting with you and supporting your needs.

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:*
Pronouns:*
Primary Language/Language(s) Used:*
Education Level:*
Living Situation:*
Veteran Status:*
Either spouse, legal partner, parent, or child served or is serving in the United States military?*
Consent to the ADRC to transmit their personal information to the Dept. of Veterans Affairs?*
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
Healthcare Insurance Provider*
Electronic Signature*
Sign and Date

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Group Orientations

Are you interested in becoming a consumer of the Disabled Resources Center (DRC)?

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

Group Orientations

Are you interested in becoming a consumer of the Disabled Resources Center (DRC)?

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

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