Client Intake and Consent Form
Date
-
Month
-
Day
Year
Date
Household Information
Please fill out a section for each member of the household
Full Name
Relationship to Head of Household
Social Security Number
Date of Birth
Gender
Race
Ethnicity
Head of Household (Self)
Male
Female
Prefer not to disclose
American Indian/Alaskan Native
Asian American
White/Caucasian
Black/African American
Native Hawaiian/Other Pacific Islander
Hispanic
Non-Hispanic
Household Member
Male
Female
Prefer not to disclose
American Indian/Alaskan Native
Asian American
White/Caucasian
Black/African American
Native Hawaiian/Other Pacific Islander
Hispanic
Non-Hispanic
Household Member
Male
Female
Prefer not to disclose
American Indian/Alaskan Native
Asian American
White/Caucasian
Black/African American
Native Hawaiian/Other Pacific Islander
Hispanic
Non-Hispanic
Household Member
Male
Female
Prefer not to disclose
American Indian/Alaskan Native
Asian American
White/Caucasian
Black/African American
Native Hawaiian/Other Pacific Islander
Hispanic
Non-Hispanic
Household Member
Male
Female
Prefer not to disclose
American Indian/Alaskan Native
Asian American
White/Caucasian
Black/African American
Native Hawaiian/Other Pacific Islander
Hispanic
Non-Hispanic
Household Member
Male
Female
Prefer not to disclose
American Indian/Alaskan Native
Asian American
White/Caucasian
Black/African American
Native Hawaiian/Other Pacific Islander
Hispanic
Non-Hispanic
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Marital Status
Single
Married
Divorced
Widowed
Are you a Veteran or currently serving in the Military?
Yes
No
Are you employed?
Yes
No
What is your primary language?
English
Spanish
Other
If other, please list here
What services are you seeking today?
CSFP (Senior Monthly Commodities)
Emergency Food
Emergency Utility/Heating Assistance
Dial-A-Ride
Head Start/Early Head Start/GSRP
Housing
In-home Services
Meals on Wheels
Loan Closet
Take 5 Program
Walk for Warmth
Weatherization
Veteran Services
Are you currently homeless?
Yes
No
If yes, since when?
If yes, how long were you at your last address?
What type of housing do you live in?
Rental
Own
Subsidized
Other
If other, please list here
Have you received assistance from our agency before?
Yes
No
Have you received assistance from another agency in the last 6 months?
Yes
No
If yes, please check all that apply.
Bay Mills
Department of Health and Human Services
Diane Peppler Resource Center
Hiawatha Behavioral Health
Health Department
Salvation Army
Sault Housing Commission
Sault Tribe
Superior Watershed
Veteran Services
Other
If other, please list here
Has your home been weatherized?
Yes
No
Unsure
If yes, when?
Are you currently experiencing domestic violence?
Yes
No
Are you a domestic violence survivor?
Yes
No
If yes, how long ago was your most recent occurrence?
3 months
6 months
1 year or more
Does the household receive income?
Yes
No
If yes, please list source(s), amount(s), and who they are received by:
Does the household receive non-cash benefits?
Yes
No
If yes, please select all that apply
Bridge Card
WIC
Tribal Commodities
Please list the monthly amounts of each non-cash benefit received
Date
-
Month
-
Day
Year
Date
Signature
Please verify that you are human
*
Submit
Should be Empty: