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 within 48 - 72 hours (business days) if you have been accepted into the program or not.

    This form is required to receive the following services that Healing Vine Harbor provides:

    • Attend monthly TALK Workshops 
    • HELP- Short-term emergency financial assistance and food assistance
    • Community Referrals (i.e., Crisis Assistance Ministries - rent & utilities, housing, furniture, etc.)
    • Healing Bags (Toiletries & Household Items)
    • 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, housing 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).
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  • 3. Are you a Mecklenburg County resident?*
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  • Format: (000) 000-0000.

  • Intake Application (continued)

  • 8. Please read and check boxes to affirm applicant meets entry criteria:*
  • 9. Do you give permission to be contacted by text for more information if needed? Please note: carrier charges may apply.*
  • 10. Sex:*
  • 11. Preferred Pronoun:*
  • 12. Ethnicity:*
  • 14. Preferred Language:*
  • 15. U.S. Citizen, or do you have current documentation to reside in the United States?*
  • 17. Have you served in the military?*
  • 18. Do you have a disability?*
  • 20. Have you ever been diagnosed and/or treated for a psychological disorder or substance abuse?*
  • 21. Have you ever been hospitalized for the disorder or substance abuse?*
  • 22. If so, was it in the:*
  • 24. Are you currently using any of the following substances (check all that apply):*

  • Intake Application (continued)

  • 26. Have you ever been arrested or convicted of a crime?*
  • 27. Has there been any income in the household in the past 30 days? Include earned and unearned income. Include all paystubs received by any household members during this period. If anyone receives unemployment, SSI, SSA, VA benefits, retirement pension, child support, disability payments, or income from any other source, you must provide verification of that income.*
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  • 28. Do you rent or own your home?*
  • 29. How do you heat your home?*
  • 30. Marital Status:*
  • 31. Do you have any children under 26? If yes, complete next section.*
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  • Do you have legal custody?
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  • Do you have legal custody?
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  • Do you have legal custody?
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  • Do you have legal custody?
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  • Do you have legal custody?
  • 35. Are you pregnant?*

  • Intake Application (continued)

  • 36. Are you currently employed?*
  • 36a. Are you willing and able to work?
  • Format: (000) 000-0000.
  • 40a. What are your work days? Check all that apply.*
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  • 41. What HVH services are you applying for (select all that apply):
  • 41a. What do you need emergency help/assistance with (select all that apply):
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  • 46. Have you applied for services from other organizations in the last 90 days?*
  • 48. Are you currently receiving services and/or assistance from other organizations?*
  • 51. Have you received services from Healing Vine Harbor in the past?*
  • Format: (000) 000-0000.
  • 55. Would you like to participate in our year-round program?*

  •  

    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. 

  • FOR OFFICE USE ONLY

  • Application approved:
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  • Should be Empty: