Aging, Disability and Caregiver Resources: Request for Services Form

 
To request service information for yourself or another adult, complete and submit this request for services form. The information you provide will help us determine how we can best help you.

Once we receive your request, an Information Specialist will contact you during office hours (8:00 a.m. to 4:30 p.m., Monday - Friday).

To report possible abuse, neglect or exploitation of an adult who is at least 60 years old or older, or is at least 18 years old and is incapacitated, call the Adult Protective Services Hotline at 703-324-7450 (TTY 703-222-9452). Your identity as the reporter will be confidential.

Request for Service Information

Required fields are indicated using a red asterisk (*).
Date Request Submitted 4/24/2014
What is your relationship to the person needing services?
*



Your First Name *
Your Last Name *
Your Daytime Telephone Number *
Your E-Mail Address
Your Alternate Telephone Number
If you have the person's permission, please complete the following information about the person in need of services:
First Name (if different from above)
Last Name (if different from above)
Telephone Number
Address 1
Address 2
City
State
Zip Code  
Does the person have a hearing loss that requires Virginia Relay services?
Age
Does the person speak English?
What is the person's primary language (if not English)?
Does the person live


If "Other", please specify
What type of help is needed?
An Information Specialist will try to contact you clarify information and discuss services.
Do you prefer to be contacted by

The following information may be needed: Person's income (and spouse's income, if married) and date of birth.
You are welcome to call the Aging, Disability and Caregiver Information Line directly (703-324-7948, TTY 449-1186) at your convenience between 8:00 a.m. and 4:30 p.m., Monday - Friday. 
Can you tell us how you heard about us?
















Thank you for your interest in the Adult & Aging Services offered through the Fairfax County Department of Family Services.
Fairfax County is committed to a policy of nondiscrimination in all county programs, services and activities and will provide reasonable accommodations upon request.  To request reasonable accommodations call 703-324-7948 or TTY 703-449-1186.
Please read the following before submitting.
I understand that submitting this Request for Services Information form does not guarantee that I will receive any services as there are eligibility requirements that must be met.

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