Client registration

Client Intake Form

Enter your information below. When you're done, click the submit button at the bottom of the form. If you're not sure about something, contact SDA Elderly Care and Referral Service, Inc. dba SDA Elderly Care at 407-757-0119 for support.

Identification

First Name *

Middle Name

Last Name *

Suffix

Date Of Birth

Social Security Number

What Is Your Age?

Head Of Household

Type YES If You Agree With Terms and Conditions. — Required *

Street Address

Address

Apt #

City *

State *

Zip

Select Language

County *

Contact Information

Phone *

Description

ex. Home or Cell

Ext.

Email Address

Demographics

Choose Your Ethnicity

Choose Your Race — Required *

Choose Your Gender — Required *

Choose Your Educational Status

Contact By Agent

Emergency Contact Full Name

Emergency Contact Area Code And Phone Number

Emergency Contact Email

Current Living Situation

What Is Your Current Living Situation?

Disability & Income

Choose Your Disability Status — Required *

Are You Homeless? — Required *

Choose Your Smoker Status — Required *

Please Explain Your Disability:

What Is Your Monthly Income? — Required *

Would You Like To Supplement Your Income? — Required *

Select Type Of Job — Required *

Do You Have Medical Insurance?

If YES, Please List Your Type Of Insurance Provider

What Additional Benefits Or Information Are You Interested In? (A Licensed Insurance Agent May Call) — Required *

Extra-Help with prescription drug costInformation on federal, state, and local assistance programsLow-income housing placementJob assistanceHealth and wellness programMedical insurance information

Health & Wellness / Pets

Are You Interested In A Health & Wellness Program? — Required *

Choose Your Pet Status — Required *

If You Wish To Express Any Additional Needs Or Interests, Please Write Your Message Here:

Request Assistance

Requested Documents

Government Issued ID

Verified Income Statement

Optional. You can register without uploading anything. Attachments must total no more than 4 MB.