Intake Form

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Client Request Form

Perfect Generation Ministries,Inc. 501(C)(3) Nonprofit 443-583-8909 or Perfectgenerationfamily@gmail.com
Have you received services from PGM the past 2 years?*

YesNo
If Yes, What name would your file have been under?
Today's Date:

MonthDayYear
What is your specific need today? (Please only one and select the most urgent need.)

Food assistanceTutoring servicesHousing referralEmployment assistanceInternship opportunitiesMentoring program (Mandatory for all youth)Healthcare resourcesDomestic Violence AssistanceLaw Enforcement Bridge program (Mandatory for youth)Other:Other
Full Name*

First NameMiddle NameLast Name
D.O.B.*

MonthDayYear
Last four SSN#:*
Personal Phone:

Area CodePhone Number
Alternate Phone:

Area CodePhone Number
Physical Address:*

Street Address

Street Name, Lot / Apt. #

CityState

Zip CodeCountry
Is this Apt/House/Mobile home?
Complex Name:
Mailing Address:

Street Address

Street Name, Lot / Apt. #

CityState

Zip Code
E-mail
Status:
Mate's Name:

First NameLast Name
Mate's D.O.B.:

MonthDayYear
Mate's SSN:
Which Church do you attend?
Do you have Children at home?

YesNo
Total in Family:
Total in Household:
Child Info:
Are there others in your home besides you, your mate, and/or children listed above?
How long have you lived at your address?
Have you been a resident of Maryland (Howard County) for 6 months or longer?

YesNo
Do you...
Staying with Someone?
Full Name

First NameLast Name
Relationship:
Phone Number

Area CodePhone Number
How long do you plan to stay?
Does an agency assist you with your rent?

YesNo
If Yes, please fill out below. If No, leave blank move on to Rent or Mortgage amount.
Which one Assists?
Phone Number

Area CodePhone Number
Are you current on your rent or mortgage?

YesOther
Due Date:

MonthDayYear
Amount owed Eviction or foreclosure notice?
Income & Expense evaluation section

Please type numbers only, this is for monthly income totals.

Household Members Income*

	Client's Amt.	Mate's Amt.	Other
Food Stamps
Cash Aid
Disability
Vet's Disability
Other Grants
Medi-Cal/Medicare
WIC
Self-Employment
Wages(Net)
Unemployment
Social Security (Retirement)
Retirement/Pension
Veteran’s Retirement
Child Support/Alimony
Other

Total Household Member Income

Household Members Expenses*

	Client's Amt.	Mate's Amt.	Other
Rent/Mortgage
Electricity/Gas(PG&E/MID)
Other Utilities(W/S/G)
Phone
Health Insurance
Medical Bills
Payday/Rent to own Loans
Education(books, supplies)
Other (Cigs./Alcohol)

Total Household Member Expenses
Income minus Expense Balance
If balance is a negative amount, please state how you make it work since you spend more than you make?
Who referred you? (Please be specific.)

First NameLast Name
Do they recieve services through PGM?

YesNo
Phone Number

Area CodePhone Number
Have you applied elsewhere for assistance?

YesNo
Other:
What Happened?
Do you have a caseworker?

NoOther
Caseworker Name

First NameLast Name
Phone Number

Area CodePhone Number
May we Contact?

YesNo
Details about Needs
Please share a little bit about the circumstances that led you to have this need.
Future Direction
Will your household size change in the next 3 months?

YesNo
PGM provides resoucres for classes in budgeting, nutrition & exercise, soft vocational skills and healthy relationships. Would you like to know more about these opportunities?

YesNo
Verification Documents In order to verify the information please upload your Identification Card (Driver's license or State ID) and if you are requiring health care assistance, like therapy or care. Please upload your insurance card. You can upload legible photos of the necessary documents below.
Upload a File

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Upload a File

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Tell PGM your story: *
We hope you have been encouraged by getting an opportunity to share your story. As we work with you over the next few days, we want to encourage you, believing that God values you and wants to improve your life.
Please sign to approve this document (click and hold mouse to draw signature, or with finger on mobile)
Signature

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Client Request Form

Income & Expense evaluation section

Details about Needs

Future Direction

We hope you have been encouraged by getting an opportunity to share your story. As we work with you over the next few days, we want to encourage you, believing that God values you and wants to improve your life.