Northeast Nebraska Community Action Partnership
Basic Intake Form Page 2
Head of Household Name
*
First Name
Last Name
Relationship to Head of Household
*
Spouse/Partner
Child
Other Relation
Other Non-Realation
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
Gender
*
Male
Female
Male to Female
Female to Male
Gender Non-Conforming
Race (Check all that apply)
*
Asian
White
American Indian/Alaska Native
Black/African American
Native Hawaiian or Pacific Islander
Ethnicity
*
Hispanic/Latino
Non-Hispanic/Latino
Are you Disabled
*
Yes
No
Long Term Disabled
Yes
No
Type of Disability
Physical
Mental
Developmental
Chronic Health
HIV/AIDS
Substance Abuse
Other
Health Insurance Status
*
United HealthCare (Medicaid)
WellCare (Medicaid)
NE TotalCare (Medicaid)
Medicare
SCHIP
Employer Provided
VA/Military Benefits
Private Pay-Direct Purchase
State Insurance for Adults
None/Un-Insured
Education Level
*
No Schooling
PreK - 4th grade
5th - 6th grade
7th - 8th grade
9th grade
10th grade
11th grade
12th grade
High School Diploma
GED
Post-Secondary
2 or 4 Year College Degree
Graduate or other Post-Secondary Degree
Working or in school if age 14-24
Yes
No
Answer only if person above is age 18 or over
Active Military
*
Yes
No
Veteran
*
Yes
No
Year Entered
Year Seperated
Branch
Discharge Status
Theater of Operation
World War II
Korean War
Vietnam War
Persian Gulf
Afghanistan
Iraqi Freedom
Iraq-New Dawn
Other Operation
Are you current or ever been in Foster Care
*
Yes
No
Are you/have been the victim of Domestic Violence
*
Yes
No
When?
Are you Currently Fleeing
Yes
No
Employment Status
*
Full-time
Part-time
Retired
Migrant Seasonal Farm Worker
Not Seeking
Unemployed <6 months
Unemployed >6 months
Income Received (List all income including wages, TANF, Unemployment, SSI, SSA, Alimony, Workmen's comp, etc)
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: