CLIENT HOUSEHOLD INTAKE
Complete first part of form for HEAD of HOUSEHOLD
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Address
*
Physical (include Mailing Address, if different from physical address)
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number. If no phone number, enter 0.
Format: (000) 000-0000.
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Years College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Services
Private Insurance
None
Income Per Month
(if no income, enter 0)
Employment
*
Unemployment
*
Social Security
*
TANF
*
SSI/SSDI
*
Pension
*
General Assistance
*
Other
*
Food Stamps
*
Family Type
*
Single Parent Female
Single Parent Male
Two Parent
Single Person
Two Adults NO Kids
Housing Status
*
Owner
Rent
Homeless (with roof)
Homeless (with no roof)
Housing Assistance
*
Yes
No
County
*
Barnes
Dickey
Foster
Griggs
LaMoure
Logan
McIntosh
Stutsman
Wells
Other
*Indicate of other county:
Fuel Assistance
*
Yes
No
Fuel Source
*
Oil
Natural Gas
Propane
Electric
Other
*Indicate if other fuel source:
Referred to agency by:
What type of assistance do you need?
*
0-5 Head Start
Cooling Program
Energy Share
Financial Counseling
Food Pantry
Furnace Repair/Replacement
Individual and Family Services
Weatherization
Other
*Indicate if other
The information provided by me is true and accurate to the best of my knowledge. Any and all client information will be kept confidential. I grant permission for the agency to make statistical, financial and case information available to our state and federal funders for monitoring and reporting purposes as required by their program guidelines.
*
Type First and Last Name
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Services
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount per Month
*
If no Income Amount, enter 0.
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Services
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
*
If no Income Amount, enter 0.
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Insurance
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
*
If no Income Amount, enter 0.
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
2 or 4 Year College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Insurance
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
*
If no Income Amount, enter 0.
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12 Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Services
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
If no Income Amount, enter 0.
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Type option 1
Type option 2
Type option 3
Type option 4
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
*
If no Income Amount, enter 0.
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Posto-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Insurance
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
*
If no Income Amount, enter 0.
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Insurance
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
*
If no Income Amount, enter 0.
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Services
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
*
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Services
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
*
If no Income Amount, enter 0.
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Services
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
If no Income Amount, enter 0.
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Services
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
*
If no Income Amount, enter 0.
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yen
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Enthicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Services
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
*
If no Income Amount, enter 0.
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Medicaid
Medicare
Indian Health Services
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
*
If no Income Amount, enter 0.
If there are additional household members, please select Yes.
Yes
Back
Next
Social Security Number
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Relationship to Head of Household
*
Gender
*
Male
Female
Disabled
*
Yes
No
Veteran
*
Yes
No
Food Stamps
*
Yes
No
Race
*
White
Asian
Black
Native American
Other
*Indicate if other race:
Ethnicity
*
Hispanic
Non-Hispanic
Education
*
0 - 8
9 - 12/Non-Graduate
High School Graduate/GED
12+ Some Post-Secondary
2 or 4 Year College Graduate
Medical Coverage
*
Mediciad
Medicare
Indian Health Services
Private Insurance
None
Income Source
*
If no Income Source, enter NONE.
Income Amount Per Month
*
If no Income Amount, enter 0.
Back
Next
Submit
Should be Empty: