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2. Wilmer Senior Services

   Client Intake & Service Request Form

6. Name*
7. Date*
   Date
9. Home Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Email Address*
18. Gender*

    1. Female
    2. Male
19. Date of Birth*
    Date of Birth
20. Primary Language
22. Ethnicity
    -- Select One --Hispanic or LatinoNon-Hispanic or LatinoEthnicity Not Reported
23. Race (check all that apply)

    1. White
    2. Hispanic
    3. American Indian
    4. Asian
    5. African American
    6. Native Hawaiian or Pacific Islander
    7. Other Race
    8. Race Not Reported
24. Married Status
    -- Select One --MarriedWidowedLife Partner/CohabitantSeparated/DivorcedSingle
26. Referred to Us By
    -- Select One --Texas Department of Family & Protective Services (DFPS)Texas Department of Assistive & Rehabilitative Services (DARS)Texas department of Aging & Disability Services (DADS)Texas Department of State Health Services (DSHS)Home & Community Care OrganizationFamily MemberDoctorAssisted Living FacilityHospitalOther
28. If "Other" Please Tell Us Who
30. Applicant Signature*

    By signing this form, you agree and acknowledge that 1) your application will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your electronic signature is valid and binding upon you to the same force and effect as a handwritten signature.

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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field