Cleveland Chesed Center Intake Form
Thank you for contacting us for assistance. Please fill out the form below so that we can determine how we may assist you.
Head of Household
*
First Name
Last Name
HOH Date of Birth
*
-
Month
-
Day
Year
Date
HOH Email
example@example.com
Spouse
First Name
Last Name
Spouse Date of Birth
-
Month
-
Day
Year
Date
Spouse Email
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
*
Please enter a valid phone number.
Cell Phone #1
Please enter a valid phone number.
Cell Phone #2
Please enter a valid phone number.
If the Chesed Center would offer text message alerts, would you like to opt in?
Yes, Cell Phone #1
Yes, Cell Phone #2
No thank you
Emergency Contact Name (someone outside of your household)
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Relationship between client and emergency contact
*
Additional Household Members
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Does this
person currently
reside in your house?
Household Member 2
Yes
No
Household Member 3
Yes
No
Household Memeber 4
Yes
No
Household Member 5
Yes
No
Household Member 6
Yes
No
Household Member 7
Yes
No
Household Member 8
Yes
No
Household Member 9
Yes
No
Household Member 10
Yes
No
Household Member 11
Yes
No
Household Member 12
Yes
No
Household Member 13
Yes
No
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Next
Is the Head of Household currently employed?
*
Please Select
Yes
No
If no, is the HOH looking for work?
What type of work (HOH)?
If unemployed, what is the reason for unemployment?
Is the Spouse currently employed?
*
Please Select
Yes
No
NA
If no, is the spouse looking for work?
What type of work (spouse)?
If unemployed, what is the reason for unemployment?
Between what % does your TOTAL HOUSEHOLD income fall?
*
Under 100%
100%-199%
200%-299%
300%-399%
Over 400%
What are your approximate total monthly fixed expenses (i.e. rent, car payments, tuition, etc. that is paid monthly)?
*
What are your approximate total monthly variable expenses (food, clothing, houehold purchases, etc)?
*
Do you or anyone in your household currently receive any of the following services/benefits
*
No, not receiving assistance
Yes, receiving Assistance
$ Amount (if applicable)
I have an application pending
SNAP (incl amount)
WIC
SSI (incl amount)
SSD (incl
amount)
Medicare
Medicaid
Unemployment (incl amount)
PIPP
HUD
If you receive other benefits or assistance, please describe below:
Would you like assistance applying for any of the above programs?
*
Please Select
Yes
No
If you applied for any of the above programs, did you receive assistance with your application and from whom?
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Next
Do you have a religious affiliation?
*
Please Select
Yes
No
Prefer not to answer
If yes, what affiliation(s)?
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Next
How did you find out about the Chesed Center?
*
If you were referred to our organization, who referred you?
Have you sought services from Gesher Cleveland in the past 12 months?
*
Please Select
Yes
No
Have you sought services from JFSA in the past 12 months?
*
Please Select
Yes
No
What services are you seeking from the Cleveland Chesed Center or one of our affiliate organizations?
*
Food and Household necessities (year round)
Clothing
Assistance applying for government programs
Job placement
Job training/readiness
Mental Health Services
Case Management
Personal finance/household budgeting guidance
Passover Food Package
Other, please specify:
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Next
For the purpose of referral or additional services, please indicate below which partner agencies you give permission to Cleveland Chesed Center staff to share information contained in this application in order to best meet your family's needs:
*
Gesher Cleveland
JFSA
Naaleh
Matan B'Sayser
Tomchei Shabbos
Bikur Cholim
Any affiliate agency that might be able to help
I do not give consent to share my information
By entering your name below, a signature of consent, as specified above, is implied.
*
First Name
Last Name
Submit
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