Service Request Form

This form is designed for requesting services. You can order services with just a few clicks.
1. Answer the questions in the request form.
2. Attach the required documents to the request form.
3. Once all required information is submitted, an official request form in PDF format will be generated.
4. This document will be sent by email to a SENJORO staff member.
5. A SENJORO staff member will coordinate the provision of services and partial funding with your municipality on your behalf.
6. All submitted data will not be shared with third parties (except municipal staff).
7. Friendship begins!

Do you need home services for yourself?

Yes No, I am filling out the request for someone else

Person filling out the request:

*First name :

*Last name :

*Address :

*Phone number :

*Email :

What is your relationship to the person who needs the services?

Son/Daughter Grandson/Granddaughter Brother/Sister Relative Neighbor Other

Person who needs home social services:

*First name :

*Last name :

Personal code (date of birth if not a Lithuanian citizen) *:

Municipality *:

City *:

Street *:

House / Apartment No. *:

Phone:

*Email :

Social services would help address the following social issues:

Raising a child (children) Raising a child (children) with a disability Due to illness and/or disability Taking care of a person due to illness and/or disability Experiencing social risk (e.g., lack of skills to care for and raise minor children, inability to manage one’s life independently) Going through a crisis (e.g., divorce, loss of loved ones, addictions, etc.) Adapting to the social environment and developing skills to solve arising problems Lack of housing or a safe home environment Other (please specify):

Briefly describe the situation and circumstances, and provide any other relevant information, preferences, or comments:

Would you like SENJORO to provide the services?

Yes, I would like SENJORO to provide the services I will decide on the service provider later

Who are the services for?

Individual Family

*Family member’s first name :

*Family member’s last name :

*Family member’s personal code (date of birth if not a Lithuanian citizen) :

Family member’s status:

Spouse Cohabitant

Please provide information about decisions regarding the allocation of social services via:

Post Email

I CONFIRM THAT I AM INFORMED AND AWARE THAT:

I confirm that the information provided is correct.

I undertake to provide the institution organizing social services or the social service provider with information and documents necessary to determine the need for social services, to organize, assign, and/or provide social services. I also undertake to inform the municipal administration or social service provider about any changes in my (family’s) income and assets during the period of receiving social services within 30 calendar days from the date such changes occur.

I am informed that the municipal administration, in accordance with the procedures established by the legal acts of the Republic of Lithuania and the European Union regulating personal data protection and processing, will obtain and process personal data and information specified in this form and in legal acts regulating the assignment and administration of social services, about me and persons living in the same household, based on which the right to social services is determined, from registers, state and internal administrative information systems, and other information systems. The purposes of personal data processing are to assess eligibility for social services, administer social services, and account for used funds. Personal data are processed in accordance with Regulation (EU) 2016/679 (General Data Protection Regulation), the Law on Legal Protection of Personal Data of the Republic of Lithuania, SPIS regulations, and other legal acts regulating data protection and processing. Documents are stored by the municipal administration in accordance with the Law on Documents and Archives of the Republic of Lithuania. Data subjects’ rights are exercised in accordance with the procedures of the municipal administration or the Ministry of Social Security and Labour of the Republic of Lithuania, depending on where the request is submitted, in compliance with Regulation (EU) 2016/679. Information on personal data processing under Article 13 of Regulation (EU) 2016/679 will be provided by the employee of the institution receiving my application for social services. For the purposes of providing social services, information about me (and my family members) may be collected from other institutions, and data about assigned social services may be provided to other institutions in accordance with legal requirements while ensuring confidentiality. The municipal administration may request additional documents confirming the accuracy of the data provided by me (and my family members). If I intentionally provide incorrect information, the provision of social services to me (or my family) may be suspended or terminated.

Signature

Please sign using your mouse or finger on a phone/tablet screen:

↻ Clear

Document of the person who needs services

Document type:

Additional documents:

Document type