How Can We Help You?

Society’s Assets is happy to assist you with information, in-home care and independent living services. Please fill out the brief form below and click on the "submit" button to send the information to us for prompt review. If you choose to contact us via this form, the information you provide will only be used to connect you with the staff person best suited to serve your needs. That person will contact you by telephone to discuss your personal needs. You may also contact the agency using e-mail: info@sai-inc.org

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Service Information Request Form

Full Name of Person needing assistance:

Please check the County in which services are needed (please click in box):
Racine	Kenosha		Walworth		Other
Name of person inquiring about services (if self, please write "self". If Professional, please include organization name):

Contact information of person inquiring about services:
Daytime Phone :		Evening Phone:		E-mail:
Preferred time & day for contact/Preferred telephone #:
Time: Day of Week: Preferred Phone:

Type of Services interested in (check box of all that apply):
Housekeeping	Meal preparation		Nursing Home Transition		Bill Paying
Grocery shopping	Laundry		Wound Care		Housing
Bathing	Dressing		Peer Network		Transportation
Companionship	Skilled Nursing		Financial Medical Benefits		Advocacy
Home Modification	Care Management		Disability Resources		Adaptive Equipment

Other

Date services are needed if known:
Day/Month/Year (dd/mm/yyyy):

Home

Thank you for your interest in Society’s Assets, Your information will be reviewed by our staff and you will be contacted within one business day by someone with expertise in the areas you indicated above. If you need immediate assistance, please call our home office at: 1-800-378-9128 or 1-888-840-9761 TTY and ask to speak with the nurse on call.

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