Adult Day Care Online Form

Contacts

Mailing Address:
The Lighthouse of Houston
3602 West Dallas
Houston, Texas 77019
Voice: 713-527-9561; Fax: 713-284-8451
For Driving Directions, Click Here– (links to Google Maps)

Education Programs:
713-284-8445
Volunteer Services: 713-284-8473
The Center for Education and Adaptive Technology
3602 West Dallas
Houston, Texas 77019
Voice: 713-284-8446; Fax: 713-284-8451

Community Services Center
3602 West Dallas
Houston, Texas 77019
Voice: 713-284-8494; Fax: 713-284-8468
E-mail: czander@houstonlighthouse.org

Community Services Center-Southwest
8640 Wednesbury
Houston, Texas 77074
Voice: 713-995-1243; Fax: 713-995-4581
E-mail: czander@houstonlighthouse.org

Living Centers I and II
E-mail: smoran@houstonlighthouse.org

Reflections, the Lighthouse Store
3602 West Dallas
Houston, Texas 77019
Voice: 713-284-8466
E-mail: reflections@houstonlighthouse.org

Customer Service (Information on Industrial Production, Material Safety Data Sheets, Pricing, Order Placement, Shipping and Routing, Customer Service)
3602 West Dallas
Houston, Texas 77019
Voice: 713-526-8251; Fax: 713-526-9841
E-mail: custserv@houstonlighthouse.org

For specific information, contact:
Adult Day Care Services – czander@houstonlighthouse.org
Customer Service – custserv@houstonlighthouse.org
Diabetes Education – mthompson@houstonlighthouse.org
Lighthouse Products – atorres@houstonlighthouse.org
Recreation Services – recreation@houstonlighthouse.org
Public Relations – rdawson@houstonlighthouse.org

Client Name: (required)

Address:

City:

State:

Zip:

Phone :

Email: (required)

DOB:

Sex:

Race:

Referred By:

Contact Person:

Contact Phone:

Relationship to Client:

Living Situation:

Primary Physician:

Physician Phone:

Physician Phone:

Presenting Medical Diagnoses:

Hospitalizations and Surgeries:

Medications:

Allergies:

(Check All That Apply) Insurance and Income Information

Medicaid#:

Medicare#:

Monthly Income:

Income Source:

Funding Source:

Caseworker:

Caseworker Phone:

MCC Program - Entry Date:

MCC Program - Withdrawal Date:

Social History Information

Marital Status:

Family Information

#Children:

#Brothers:

#Sisters:

Birthplace:

Time in Houston:

Previous work history:

Please list other services currently provided:

Transportation Resources:

Daily Care at Home is Provided By: (meals, hygiene, medication)

Please List Any Special Dietary Restrictions or Needs and Explanation of Needs:

Additional Comments:

Client Guardian Signature: