Program Participant Intake and Consent Form

Live Life With Purpose International

NEEDS ASSESSMENTS
THE S.H.E.E.R.O PROJECT

In order to receive this free or low-cost programming, you are required to complete this form so we can best meet your needs . All the information provided is confidential and will not be shared with any 3rd party.
General Information
Full Name *

First Name Last Name
Birth Date *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Phone Number *

Area Code Phone Number
Gender
How did you hear about this program?
Income Verification
Income Source *

Employed Self-employed Unemployed SSI/SSDI TANF NO income
Monthly household income $blanks. Rent or Mortgage blank
Total Number of people living in the household
Household receiving

Free/reduced lunches Food Stamps Childcare Assistance Program (CCAP) Housing Assistance WIC Veterans Benefits
Type of Health Insurance

Medicare Private Insurance Medicaid Veterans Benefits
What do you need assistance with?
I have read and understand that completion of this form is no guarantee of services. I understand that I may not be turned away based on race,gender,religion,sexual orientation or ability to pay for services.
Should be Empty:

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Live Life With Purpose International