• Taconic Resources for Independence, Inc.'s logo. With subtext: Advocacy, Inclusion, Independence.

  • This is an additional form to the initial Intake Packet. A new form is to be completed for all returning consumers. If you have any questions about this form, speak with your Advocate directly, or you may ask the front desk staff to assist you: 845-452-3913

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you the Head of your Household?*
  • What is your Marital Status?*
  • What type of housing are you currently living in? (Housing Status):*
  • What is your Source of Income?*
  •  
  • Should be Empty: