Orcas Community Resource Center Client Intake Form

Client Intake Form

Orcas Community Resource Center
Date

Month Day Year
Your Personal Details
Client Name *

Prefix First Name Last Name
preferred name and pronoun
she/hers he/his they/their
Cell Phone

Area Code Phone Number
Home Phone

Area Code Phone Number
Email
example@example.com
Preferred Method of Contact
Physical Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact Name and Phone
Date of Birth *

Month Day Year
Date
Gender *
Race *
Ethnicity (Hispanic or Non-Hispanic) *
Primary Language *
Highest Level of Education
Veteran? *

YES NO
Disabled? *

YES NO
What brings you to the Resource Center today? *
How can we help?
Have you sought out assistance previously from OCRC or any other local agencies?

Food Bank Lions Club Senior Center Veteran's Assistance DSHS OPALCO Project Pal Community Wellness Program (CWP) OPALCO Energy Assist Program Dental Van Emergency Assistance Safe San Juans Rental Assistance Transportation Voucher Program (TVP) Other
Current Housing *

Own Rent Homeless Temporary Roomer/Boarder
Monthly Mortgage or Rent Amount $ *
How do you currently heat your home? *

Electric Propane Wood
Health Insurance *

Medicaid Medicare Uninsured
If on Medicaid, please select insurance carrier

Molina UnitedHealthcare Community Plan Amerigroup Washington, Inc. Coordinated Care Corporation (CCC) Community Health Plan of Washington (CHPW)
Employment Status *

Full Time Part Time Unemployed Retired Disability
If employed, list employer
Household Members
Household Gross Monthly Income (before taxes) required
Support Network
My signature below indicates that all of the information on this form is both true and accurate. OCRC may use this information to determine elibility for programs and benefits as well as provide data to determine local, county, and state program needs. OCRC may transfer the information contained within this document to their private database. OCRC will not use the information contained in this application for any other reason without my written consent.
Signature (required) *

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