New Client Information 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)

Parent's Name:

Address:

City:

State:

Zip:

Date of Birth:

Gender:

Home Phone #:

Cell Phone #:

Work Phone #:

Email: (required)

School District:

Check The Following That Apply

Ethnic Group:

Vision Level:

Disability Group:

Other:

Mode of Mobility:

Child's Language:

Other:

Parent's Language:

Other:

Self Care Tasks (Feeding):

Self Care Tasks (Toileting):

Household Income (yearly):

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