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 711). Your identity as the reporter will be confidential.
Request for Service Information
*Required fields are indicated using a red asterisk ().**

Date Request Submitted		6/10/2023
What is your relationship to the person needing services?	*	SelfOther Relative SpouseFriend DaughterOther SonGuardian
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?		YesNo
Age
Does the person speak English?		YesNo
What is the person's primary language (if not English)?
Does the person live		Alone With Spouse With Family Other
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		Phone Virginia Relay E-Mail

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 711) at your convenience between 8:00 a.m. and 4:30 p.m., Monday - Friday.

Can you tell us how you heard about us?		Alzheimer’s Association Alzheimer’s Family Day Center Driving by Faith-based or Civic Organization Flier/Brochure Friend or Family Golden Gazette Hospital Internet Long Term Care Insurance News Media Physician Presentation or Resource Fair Private Case Manager Rehab/Long Term Care Facility Senior Plus Website Other

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 711.

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.