Intake Application Form

Intake Application Form
The mission of Healing Vine Harbor (HVH) is to reduce the number of single women living in shelters or unsafe situations, providing a pathway out of poverty to ensure self-sufficiency. We Transform Lives One Woman at a Time through independent living skills such as financial literacy, educational preparation, employability readiness, mentoring and much more.

Our HVH Team will interview and evaluate each application on a case-by-case basis. We will carefully select applicants. We will notify qualified applicants after review.

This form is required to receive the following services that Healing Vine Harbor provides:
- Attend monthly TALK Workshops
- Healing Closet (clothing and household items)
- HELP- Short-term emergency financial assistance and food assistance
- Community Referrals (i.e., Crisis Assistance Ministries - rent & utilities, housing, furniture, etc.)
- Healing Bags (Toiletries/PPE)
- Any additional services that may not be listed
(visit us at www.healingvineharbor.org)

The information in this document will remain confidential. In exceptional circumstances, permission from the client will be sought before any information is disclosed.
If you were referred to us by an agency, please provide a copy of the referral on the agency's letterhead, signed by the referring worker. Referring workers must submit their agency’s consent for release of information (signed by applicant), verification of homelessness (if applicable), documentation of your income [either a fixed income award letter dated within the last 90 days, or your two most recent consecutive paystubs (see item 40c in this application)], and a signed case summary on referring worker’s agency letterhead. The summary must include the following information:
- Strengths and areas of concern.
- Presenting issues (including health, mental health, substance abuse and criminal history).
- Employment information (length of service, position, salary, and schedule).
- If not employed, source of income/amount received (award letters or statements from an awarding agency must have been issued within 90 days of the appointment date).
1. If you were not referred, how did you hear about us.*
2. Name*

First NameLast Name
1a. Upload copy of referral agency letter(s) and an agency consent of release.

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3. Current address (If homeless, where did you stay last night?):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4. Date of Birth:*

MonthDayYear
Date
4a. Please upload a copy of your government issued ID and a copy of your social security card. These are required for emergency financial assistance referrals. *

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5. Your Age:*
6. Email*
example@example.com
7. Best Contact Phone Number:*
Please enter a valid phone number.

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Consent to Release Information

To assist you, Healing Vine Harbor needs your consent to contact your landlord, mortgage holder, utility companies, other vendors, resource providers and household members for any reasonable purpose to resolve your emergency. My signature below indicates that I request and authorize Healing Vine Harbor to contact appropriate individuals for the purpose of verifying information to determine my eligibility for available assistance, negotiating amounts required, committing funds and paying bills by check or electronic transfer. By my signature, I attest that the information I have provided and will provide is true and complete to the best of my knowledge. I understand that I am not required to give my consent; however, I understand that I will not receive assistance if I do not give it. Information is confidential and used only with partnering organizations.
Signature*

Clear
FOR OFFICE USE ONLY
Intake staff:
Application approved:

YesNo
Date:

MonthDayYear
Date
Should be Empty:

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FOR OFFICE USE ONLY