Client Application

› Client Application

Thank you for your interest in becoming an SCNOVA Client. Client is the term we use for the seniors we serve. If you want to receive services such as Transportation, Food Delivery, Friendly Caller, Friendly Visitor, Minor Home Repair, or Health Advocacy, please first complete a Client Application here. You do not need to complete a client application for AIL, Caregivers Support, Health & Wellness classes, or Social Events – although all our clients can avail themselves of these services.

There are three ways to complete a Client application:

fill out the online form below (preferred)
download the Client Agreement here , fill it out, sign and return it by email to: online@scnova.org or mail it to Attn: Volunteer, SCNOVA, 541 Marshall Road SW, Vienna, Virginia 22180.
Download the client Information Sheet here, fill it out on line and email it to office@scnova.org
If you have questions or need assistance please contact our office at (703) 260-9568.

Step 1 of 3

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Are you completing this form for yourself, or for someone else?
- Myself
- Someone Else
You are completing this application for someone else. What is your Name?*
First Last
Phone*
Email

Please complete the rest of the Application with only the Applicant's information
Client Applicant Name*
First Last
Applicant Birth Date*
MM slash DD slash YYYY
Residence Address
Street Address Address Line 2 City ZIP Code
State*
Cell Phone
Home Phone
Email (if Applicant has no email, please enter none@none.com)*
How did you hear about the Shepherd's Center of Northern Virginia?
Are you a Veteran?
- Yes
- No
Branch of Service
Primary Language
What is your living arrangement?*
Please provide the name of Applicant's Faith Congregation (or NA if not applicable)*
Covid Immunization Status
- Yes
- No
- Booster
Do you have an impairment we should know of (memory, speech, physical, walker/cane, etc.)? If yes, briefly explain below.
Do you have any other Medical Conditions that we should know of? If yes, briefly explain below.
What is your 1 Person annual income? (needed for reporting overall statistics, never associated with names)*
What is your 2 Person household annual income? (needed for reporting overall statistics, never associated with names)*
What is your race/ ethnicity?*
Female Headed Household (single female is head of household)
- Yes
- No
Familial Status (household w children under 18)
- Yes
- No
Disabled
- Yes
- No
You or another in the household having a physical or mental impairment that substantially limits one or more major life activities; hearing, visibility, mobility, chronic alcoholism, mental illness, AIDS.
Elderly in household (person aged 55 or older)
- Yes
- No
Participant in TANF (Temporary Assistance to Needy Families)
- Yes
- No

Emergency Contact
Emergency Contact Name:
Phone:
Email
Relation to Applicant
Emergency Contact Address
Street Address Address Line 2 City ZIP / Postal Code
State*
What Shepherd’s Center services are you interested in? Choose as many as you wish.
- Transportation
- Friendly Caller
- Friendly Visitor
- Handy Helper
Do you have any comments or questions we can address when we contact you?
CAPTCHA
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Untitled
- First Choice
- Second Choice
- Third Choice
Untitled
- First Choice
- Second Choice
- Third Choice
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Email
This field is for validation purposes and should be left unchanged.

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Services We Offer

Adventures in Learning (Classes)
Caregivers Support Group
Food Delivery
Friendly Caller Program
Friendly Visitor Program
Health & Wellness
Minor Home Repairs
Senior Citizen Transport
Social Events
Service Territories

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Helping in any way makes a difference.

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541 Marshall Rd SW

Vienna, VA 22180

(703) 260-9568

Since 1998, the Shepherd’s Center of Northern Virginia (SCNOVA), a 501(c)(3) non-profit organization, has been dedicated to improving the quality of life as we age, through supportive programs and services, personal enrichment and volunteer engagement that enable our senior neighbors to live full and productive lives while aging in place.

Services

Adventures in Learning (Classes)
Caregivers Support Group
Food Delivery
Friendly Caller Program
Friendly Visitor Program
Health & Wellness
Minor Home Repairs
Senior Citizen Transport
Social Events
Service Territories

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