Client Application — Shepherd's Center of Northern Virginia

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 application here, fill it out, sign and return it by email to: online@scnova.org
If you have questions or need assistance please contact our office at (703) 260-9568.

Step 1 of 3

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
What is your living arrangement?*
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 annual income? (needed for reporting overall statistics, never associated with names)*
What is your race/ ethnicity?*

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?
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Comments
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