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Serve With Us
Contact
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are required
Today's Date:
Personal Information
Personal Information
First Name
*
Middle Name
Last Name
*
Do you use any other names? If so, please list here:
Telephone Number
*
Social Security Number
*
Date of Birth:
Do you have a Continuum ID Card?
*
Yes
No
If yes, enter Continuum ID Number:
Were you ever active-duty military?
*
Yes
No
Client doesn't know
Client refused
RACE and ETHNICITY
RACE and ETHNICITY
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Non-Latino
Client doesn't know
Client refused
What is your race? (select all that apply)
African American or Black
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
White
Client doesn't know
Client refused
Indian Health Services Program
Other
What is your gender?
*
Female
Male
Transgender Female to Male
Transgender Male to Female
Gender Non-conforming
Client doesn't know
Client refused
Can you pass a drug test?
Yes
No
If you cannot pass a drug test, for what will you fail?
Do you have a disabling condition?
Where did you stay last night?
How long have you been staying where you were last night?
Have you been continuously homeless for one year?
Yes
No
If not, what is your relation to the Head of Household?
Number of times you have been homeless in the past three years?
If 4 or more, what is the total number of months you have been homeless in the past three years?
What is the total number of months that you have continuously been homeless immediately prior to coming to this shelter?
Amount of income you receive
What type of income do you receive? (Check all that apply AND enter amount in the box below)
NONE
Alimony
Child Support
Earned Income
General Assistance (HUD)
Other (HUD)
Pension or retirement income from another job
Private Disability Insurance
Retirement Income from Social Security
SSDI
SSI
TANF
Unemployment Insurance
Veteran NonService Connected Disability Pension
Veteran Service Connected Disability Compensation
Worker’s Compensation
What type of Non-Cash Benefits do you receive? (Check all that apply AND enter amount in the box below)
NONE
Food Stamps
SCHIP
WIC
TANF Child Care Services
TANF Transportation Services
Other TANF-Funded Services
Section 8, Public Housing, or other ongoing rental assistance
Other Source, name it below
Temporary Rental Assistance
Amount of non-cash benefits you receive:
What type of Health Insurance do you have?
NONE
MEDICAID
State Children’s Health Insurance Program
Veteran’s Administration (VA) Medical Services
Health Insurance obtained through COBRA
Private Health Insurance
State Health Insurance for Adults
Indian Health Services Program
Other
Disability Type? (Check All that Apply)
NONE
Alcohol Abuse
Developmental
Drug Abuse
HIV or AIDS
Mental Health
Physical
Chronic Health Condition (heart, diabetes, etc.)
Other
Do you expect your disability to be long term?
Yes
No
Are you receiving medical treatment for your disability?
Yes
No
Are you a domestic violence victim/survivor?
Yes
No
If yes, for domestic violence, when did it occur?
Past 3 months
3-6 Months Ago
6-12 Months Ago
More than a Year
Are you currently fleeing domestic violence?
Yes
No
Are you currently working?
Yes
No
If you are not working, when is the last time you had a job?
If you take any medication, please list:
Divider
Additional family members age 18 and under:
Additional family members age 18 and under:
CHILD'S NAME:
Social Security Number:
Date of Birth:
What race is this child? (select all that apply)
African American or Black
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
White
Multi-racial
Client doesn't know
Client refused
Indian Health Services Program
Other
Gender:
Female
Male
Transgender Female to Male
Transgender Male to Female
Other
Does she/he have Hispanic or Latin heritage?
Hispanic
Latin
Neither
Is he or she disabled?
Yes
No
Relationship to Head of Household:
Health Insurance?
Yes
No
Health Insurance Carrier:
CHILD'S NAME:
Divider
Social Security Number:
Date of Birth:
Gender:
Male
Female
What race is this child? (select all that apply)
African American or Black
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
White
Multi-racial
Client doesn't know
Client refused
Indian Health Services Program
Other
Does she/he have Hispanic or Latin heritage?
Hispanic
Latin
Neither
Is he or she disabled?
Yes
No
Relationship to Head of Household:
Health Insurance?
Yes
No
Health Insurance Carrier:
CHILD'S NAME:
Social Security Number:
Date of Birth:
Gender:
Male
Female
What race is this child? (select all that apply)
African American or Black
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
White
Multi-racial
Client doesn't know
Client refused
Indian Health Services Program
Other
What race is this child? (select all that apply)
African American or Black
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
White
Multi-racial
Client doesn't know
Client refused
Indian Health Services Program
Other
Do she/he have Hispanic or Latin heritage?
Hispanic
Latin
Neither
Is he or she disabled?
Yes
No
Relationship to Head of Household:
Health Insurance?
Yes
No
Health Insurance Carrier:
CHILD'S NAME:
Gender:
Male
Female
Social Security Number:
Date of Birth:
What race is this child? (select all that apply)
African American or Black
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
White
Multi-racial
Client doesn't know
Client refused
Indian Health Services Program
Other
Do she/he have Hispanic or Latin heritage?
Hispanic
Latin
Neither
Is he or she disabled?
Yes
No
Relationship to Head of Household:
Health Insurance?
Yes
No
Health Insurance Carrier:
CHILD'S NAME:
Social Security Number:
Date of Birth:
Gender:
Male
Female
What race is this child? (select all that apply)
African American or Black
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
White
Multi-racial
Client doesn't know
Client refused
Indian Health Services Program
Other
Do she/he have Hispanic or Latin heritage?
Hispanic
Latin
Neither
Is he or she disabled?
Yes
No
Relationship to Head of Household:
Health Insurance?
Yes
No
Health Insurance Carrier:
CHILD'S NAME:
Social Security Number:
Date of Birth:
Gender:
Male
Female
Do she/he have Hispanic or Latin heritage?
Hispanic
Latin
Neither
Is he or she disabled?
Yes
No
Relationship to Head of Household:
Health Insurance?
Yes
No
Health Insurance Carrier:
If you are a human seeing this field, please leave it empty.
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