Client Name
Client Case Number
Intake Date
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Month
/
Day
Year
Date
Mainstreams of Income
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TANF
SSI
SSDI
Food Stamps
Job Training/ Employment
Medicaid
Medicare
Veterans Health Care
SCHIP
Mental Health Care
Substance Abuse Treatment
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Eligible
Recieving
Application Support
TANF
SSDI
Food Stamps
Employment/Job Training
Medicaid
Medicare
VA Benefits
Mental Health Program
Substance Rehab
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