• FFT Intake Complete Enrollment Packet

  • DOB*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Emergency Contact Relationship*
  • FFT- Gender*
  • FFT- Living Arrangement*
  • FFT- Ethnicity*
  • FFT-Marital Status*
  • FFT- Race*
  • FFT-Military Status*
  • FFT- Health Insurance Status*
  • Percent of the Poverty Level
  • FFT- Primary Interest upon Program Entry (please choose 1)*
  • How did you hear about Edna Martin Christian Center*
  • Primary Language*
  • FFT- Highest Grade Completed*
  • If you exited the program early, your reason for leaving*
  • Working upon Program Entry?*
  • Criminal Convictions*
  • FFT - Vocational Training/Bridge Program History*
  • FFT- In-school/Training at Program Entry?*
  • FFT- Income level
  • Do you have any children ages 0-17?*
  • DOB of Child #1
     - -
  • DOB of Child #2
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  • DOB of Child #3
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  • DOB of Child #4
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  • DOB of Child #5
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  • DOB of Child #6
     - -
  • DOB of Child #7
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  • DOB of Child #8
     - -
  • DOB of Child #9
     - -
  • Employment Status*
  • Start Date of current job, if working?
     - -
  • FFT- If working is current job also longest-held job?*
  • FFT- If not working is last job also longest-held job?*

  • Credit Pull Authorization Form

  • Credit Release Authorization
    To assist Edna Martin Christian Center in its ability to provide me with financial counseling services, I hereby authorize Edna Martin Christian Center to pull my Transunion credit report and FICO score now and periodically, but not more frequently than once every six (6) months for a period not to exceed five (5) years from the date of this authorization. I understand that all inquiries by Edna Martin Christian Center into my credit constitute "soft inquiries" and will not adversely affect my credit or my credit rating. While the credit reports and scores pulled by Edna Martin Christian Center on my behalf will be used to provide me with financial counseling and/ or to track my financial outcomes, it is understood that I will not receive a copy of the credit reports. I understand that I may request a financial counseling session at Edna Martin Christian Center in the future to discuss information in any credit report and/or credit score pulled by Edna Martin Christian Center on my behalf I further understand that I may withdraw Edna Martin Christian Center's authorization to pull additional credit reports or credit scores at any time without penalty. Notwithstanding the foregoing, I understand that I have the right to dispute information with the credit bureau, to request reinvestigation, and to have corrected reports reissued to previous recipients of the credit report at issue.
    I understand that credit information is sensitive and that there may be inherent risks to accessing such data; I have had the opportunity to ask My Financial Counselor questions regarding such risks. I understand that all of my personal information will be held confidential by Edna Martin Christian Center and used only as authorized by me.
    Any questions that I may have regarding the above will be answered by a Center for Working Families Counselor at Edna Martin Christian Center. 

     

     

     

  • Date
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  • Edna Martin Christian Center Credit Report Request Form

  • DOB
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  • I authorize Edna Martin Christian Center to obtain a free credit report from www.Annualcreditreport.com.

  • Date
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  • For Office use only

  • Date that the credit report was obtained
    Staff who obtained the report

  • Credit Report was...

  • EMCC Certification and Authorization for release of Information

  • CERTIFICATION AND AUTHORIZATION FOR RELEASE OF INFORMATION
    "I certify that the information provided is correct and true to the best of my knowledge. I also understand that I may be required to verify these statements and give my consent to Edna Martin Christian Center to make necessary contacts to verify these statements. I consent to the release of any information for this purpose. I understand that I will be held responsible if I have provided false or fraudulent information to obtain services from this agency."

  • Date
     - -
  • Date
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  • APPEAL INFORMATION
    If you are denied and do not agree with the reason stated, you may appeal the decision to the Edna Martin Christian Center Board of Directors.

  • LISC Consent Form for Research

  • Edna Martin Christian Center helps participants become more financially secure by assisting them to get and keep jobs, enter and complete training, access public benefits for which they are eligible, and learn how to manage their money. Edna Martin Christian Center is working with Local Initiatives Support Corporation ("LISC") to figure out which kinds of assistance and supports are helpful to participants and which ones are not. The information you provide us during your participation in this program will be compiled with other people s data and shared, with USC to help provide better service to participants.
    Your Right to Confidentiality
    The information you provide to Edna Martin Christian Center, and LISC is completely confidential. In research reports and presentations, your privacy will always be respected and your name or other personal information that might identify you will be disclosed to the public or sold for commercial purposes.
    Benefits and Risks
    There are no special benefits or risks to you as an individual if you participate in this research; the information " will be used only for learning purposes, so that programs know the kinds of assistance and support that help people become more financially secure. Participation in this reseanh study is completely voluntary. If you do not want to pruticipate in the research, you may still continue to receive the same services and supports. Also, if you choose to participate in the research you may discontinue participation at any time without penalty.

  • Date
     - -

  • If you have any questions regarding this research or your rights, please contact:

    Immanuel Ivey: iivey@ednamartincc.org

  • PHOTOGRAPHS AND VIDEO IMAGE RELEASE

    In consideration of the receipt of good and valuable consideration, the sufficiency and receipt of which are hereby acknowledged, I agree as follows:

  • 1. I give and grant in perpetuity to Local Initiatives Support Corporation, its affiliates and subsidiaries ("USC"), and their respective representatives, agents, licensees, successors and assigns (herein collectively called "Licensed Parties") an unconditional, nonexclusive, worldvide, royalty-free, irrevocable license and right to use my name, image, biographical infonnation, performance, voice, photograph and likeness (collectively, "Image Rights") in all media and content whether now existing or later discovered or invented, prepared for or by the Licensed Parties for any and all types of advertising, publicity, marketing, promotion, exhibition and other purpose that is connected to USC's charitable mission.
    2. I agree that any materials taken, developed, produced, created, or derived therefrom by the Licensed Parties (collectively, the "Materials") that contain my Image Rights are owned by the Licensed Parties and that they may copyright such Materials. I will not authorize any other person, firm or entity to use such Materials or take any action inconsistent with the rights and license granted to the Licensed Parties.
    3. I agree that no Materials need to be submitted to me for any further approval, and the Licensed Parties shall have no liability to me or anyone else for any distortion, illusionary effect or otherwise resulting from the use of my Image Rights.
    4. I warrant and represent that (i) I am of legal age in the state in which I reside; (ii) I have the full right and authority to enter into this Photo and Video Release ("Release") and grant the license and rights described herein; and (iii) this Release does not in any way conflict with any existing commitment on my part.
    5. Everything contained in this Release is and shall be binding on me, my agents, heirs, successors, assigns and representatives. I hereby release and hold the Licensed Parties harmless from and against any and all losses, claims (including without limitation any and all claims for libel or violation of any right of publicity or privacy), actions, damages, liability, costs and expenses arising out of this Release and the use of the Image Rights by the Licensed Parties. Nothing herein will constitute any obligation on the Licensed Parties to make use of the Image Rights.

  • Format: (000) 000-0000.

  • Financial Health Assessment

  • How did you take this questionaire?*

  • How well does this describe you or your situation?

  • I could handle a major unexpected expense*
  • I am securing my financial future*
  • Because of $, I will never have what I want*
  • I can enjoy life because of the way I manage my money*
  • I am just getting by financially*
  • I am concerned that the money I have/save won't last*

  • How often does this situation apply to you?

  • Giving a gift would strain my monthly finances*
  • I have money leftover at the end of the month*
  • I am behind with my finances*
  • My finances control my life*

  • University of Wisconsin MCFS Financial Capability Score

  • Do you have a budget or financial plan?*
  • Confidence: Your ability to achieve a financial goal*
  • Confidence: Your ability to make ends meet: emergency expenses*
  • Do you have automatic savings?*
  • Was your family's expenses less than their income?*
  • Over the last 2 months have you been charged a late fee?*

  • Banking information

  • Do you have a checking account*
  • If yes, do you bounce checks frequently?*
  • If no, have you ever had a checking account?*
  • If no, what is the main reason?*
  • Do you have a savings account*

  • FFT Combined Financial Assessment (CFA) BASELINE PROFILE

  • FFT - Living Arrangement*
  • Rows
  • Products/Practices Do you have a budget (a written spending plan) for all your monthly expenses?*
  • Over the past three months, have you been able to pay your bills on time?*
  • Over the past three months, have you had to borrow from friends or family to pay for basic necessities like food or rent?*
  • Do you presently have a checking account with a bank or credit union?*
  • Do you bounce checks frequently (at least once a month for the past three months*
  • Have you ever had a checking account?*
  • What is the main reason for not having one?*
  • Do you presently have a savings account with a bank or credit union?*
  • Do you set aside money for savings on a regular basis?*
  • Do you presently have one or more active credit cards?*
  • Over the past three months, have you ...*
  • Have you ever had a credit card?*
  • Are you in a Debt Management Plan or working with a Debt Settlement or Credit Repair company?*
  • Did you file a tax return in the last tax season?*
  • Health Insurance Status (primary insurance only)*

  • Red Flags

  • Have your wages been garnished in the past year, or are you in danger of having your wages garnished?*
  • Are you in bankruptcy now (i.e. your debt has not yet been fully discharged), or are you in the process of filing for bankruptcy?*
  • If your household rents, have you been evicted in the last year, or are you in danger of being evicted?*
  • If your household owns, has your mortgage lender started foreclosure proceedings against you?*
  • Have any of your utilities been disconnected in the past year, or are you presently in danger of having your utilities disconnected?*
  • Has your car(s) been repossessed in the past year, or is it presently in danger of being repossessed?*
  • Are collection agencies presently contacting you about unsettled claims?*

  • Baseline Notes (For office use only)

  • Budget

    We are about to create a budget. Do you want it to reflect just your own finances, or the finances of your whole household? (Note to participants: please make sure all of your answers stay consistent with your response to this question.)

  • Monthly Income

    Please mark any inapplicable fields with 0 (zero)

  • Monthly Expenses

    Please mark any inapplicable fields with 0 (zero)

  • Rent, Taxes & Home Maintenance

  • Utilities

    If your utilities are combined as part of rent,please only enter what utilities for which you are directly responsible.

  • Transportation

  • Child/Dependent Related

  • Health Related Expenses

  • Credit Card/Loan Payments

  • Food

  • Personal Expenses

  • Miscellaneous Expenses

  • Monthly Net Income

  • Barriers to Success

    "Barriers" keep someone from obtaining and/or maintaining a job/career. Please select the Barriers that most apply to you. Use comment space to document additional information.

  • Barrier

  • Lack of Job Training*
  • Poor Job Search Skills*
  • Lack of Work Experience*
  • GED Needed*
  • Police Record*
  • Lack of Transportation*
  • Child Care Issues*
  • Pregnant/Parenting*
  • Homeless*
  • Victim of Domestic Violence*
  • Poor Employment History*
  • Displaced Homemaker*
  • Substance/ Alcohol Abuse*
  • Emotional Health Issues*
  • Physical Health Issues*
  • Lack of Motivation*
  • Lack of Confidence*
  • Unfamiliar with Culture/Language*
  • Financial Crisis*
  • Lack of Basic Skills*
  • Literacy Help Needed*
  • Have a Disability*
  • Ex-Offender*
  • Other*

  • Martindale -Brightwood Center for Working Families Goals Identification Sheet

  • Martindale-Brightwood Center for Working Families Job Readiness Assessment

  • Are you currently employed?*
  • If yes,*
  • Are you currently looking for a job?
  • If yes, how many applications do you complete per week?*
  • Do you have a resume?*
  • Have you been on any interviews in the past 3 months*
  • If so, how many?*
  • Do you need assistance with answering interview questions?*
  • Do you need interview clothing?*
  • Do you have a valid driver's license?*
  • If no, do you have a state ID?*
  • Do you have a GED or HS diploma?*
  • Do you have a college degree?*
  • Do you have any certifications?*
  • Are you currently in school?*
  • If no, are you interested in going to school?*

  • Program Survey

  • Are you between the ages of 17-24 years old?*
  • Do you have any children between the ages of 0-5?*
  • Do you currently have any children in daycare?*
  • In which career track are you interested?*
  • Do you need assistance with budgeting and/or managing your money?*
  • Are you a homeowner?*
  • If no, are you interested in homeownership?*
  • Are you interested in starting your own business?*
  • Are you currently enrolled in a college or other training school?*
  • If you are under the age of 18, are you enrolled in HS?*

  • Additional Information

  • Employment Record

    Current job, or last job held if not working. If you have never worked, N/A.
  • Employment start date, or approximate start date
     - -
  • If last job held, the date or approximate date, of your last work day
     - -

  • Education Record (Current School/Training Programs)

  • Education Start Date, or approximate date.
     - -

  • EMCC Benefits Screening

  • Current Benefits Information

  • Is the family already receiving benefits of any form?

  • If receiving benefits with monetary value, please list benefits received and amounts below:

  • Household Information

  • Total Household Income

  • Image field 442

  • WIC

    WIC The Special Supplemental Nutrition Program for Women, Infants, and Children - better known as the WIC Program - serves to safeguard the health of low-income women, infants, & children up to age 5 who are at nutritional risk by providing nutritious foods to supplement diets, information on healthy eating, and referrals to health care. Eligibility is based on pregnancy, parenting status and income.

  • Is the client currently pregnant or parenting a child 5 years or younger?
  • If yes, does the client meet the income requirements?(If yes, the client is eligible for WIC)

  • Hoosier Healthwise

    Hoosier Healthwise is Indiana's program for children who need comprehensive, affordable health insurance, regardless of family income, immigration status or health condition. Uninsured children can qualify for Hoosier Healthwise no matter how much money their parents earn. Children must live in Indiana and be 18 or younger.
  • Is the child uninsured?
  • Is the child an Indiana resident and younger than 18? If yes to both, the client's children may be eligible for Hoosier Healthwise.

  • Healthy Indiana Plan (HIP)

    The Healthy Indiana Plan (HIP) is an affordable health plan for low-income adult Hoosiers between the ages of 19 and 64. It's sponsored by the state and for some members requires a small monthly payment through your Personal Wellness and Responsibility (POV/ER) Account. Like Hoosier Healthwise, HIP covers doctor visits, dental care, specialty medical services, hospital care, emergency services, prescription drugs and more. HIP is eligible to Indiana residents who meet the income limits. They must be U.S. citizens or meet immigration requirements.
  • Is the parent uninsured? If yes, the client may be eligible for HIP
  • Does the client meet the income limits?

  • Medicaid Presumptive Eligibility Program (MPE)

    MPE is a program for pregnant women. MPE offers immediate, temporary coverage for outpatient health services to pregnant women who meet income requirements. There are no co-payments or premiums in MPE. In order to receive MPE, clients must go to an MPE provider who will verify pregnancy and income. If the MPE provider verifies the client's pregnancy and that they meet the income requirements, the client can get services right away.
  • Is the client currently pregnant?
  • If yes, does the client meet the income requirements? If yes to both, the client may be eligible for MPE and Moms and Babies

  • The Emergency Food Program

    The Emergency Food Program (EFP) provides food at no cost to help supplement the diets of needy low-income households. Individuals or households who are residents of Indiana and meet income guidelines are eligible. Food pantries may ask for proof of identity and residency. If the client answer yes to both of the following questions they may be eligible for EFP
  • Does the client meet the income requirements?
  • If yes, can the client meet the residency requirements?

  • SNAP

    The Supplemental Nutrition Assistance Program (SNAP) helps low-income people and families buy the food they need for good health. Benefits are provided on the Link Card - an electronic card that is accepted at most grocery stores. Most households with low income can get SNAP benefits. Children of undocumented parents may be eligible for food stamps. If the client answers yes to both questions they may be eligible for SNAP
  • Does the client meet the income requirements?
  • If yes, does a parent or child in the house have documentation of US citizenship?

  • Child Care Development Fund

    The Child Care Development Fund provides low-income, working families with access to quality, affordable child care that allows them to continue working and contributes to the healthy, emotional and social development of the child. Families are required to cost-share on a sliding scale based on family size, income and number of children in care. In addition to helping low-income, working families, the Child Care Development Fund also serves families receiving Temporary Assistance for Needy Families (TANF) and participating in education & training. If yes to both of the following questions, the client may be eligible for CCDF.
  • Is the client currently parenting?
  • If yes, is the client receiving TANF, working or in school?
  • If yes, does the client meet the income limits?

  • EAP

    The energy assistance program (EAP) provides financial assistance to low-income households to maintain utility services during the winter heating season. This is a HEATING program, and Summer Cool program (when funding is available). The amount of the payment is determined by income, household size, fuel type and geographic location. If the client answers yes to the following question, they may be eligible for EAP.
  • Does the client meet the income limits?

  • TANF

    The Temporary Assistance for Needy Families (TANF) program provides temporary financial assistance for pregnant women and families with one or more dependent children. TANF provides financial assistance to help pay for food, shelter, utilities, and expenses other than medical. To qualify for TANF, a person must be pregnant or have a child under age 19 who lives with them. All applicants must live in Indiana and be a U.S. Citizen or meet certain immigration requirements. Clients can be homeless and still qualify. If the client is not currently receiving TANF benefits and his/her monthly income is not adequate to support their family size, he/she should apply for TANF benefits. Recipients of TANF benefits are required to follow a Responsibility and Services Plan which includes employment and child support compliancy. If the clients answers yes to the following questions, they may be eligible for TANF
  • Is the client currently pregnant or parenting?
  • Does the client have sufficient income to meet their needs?

  • Supplemental Security Income (SSI) / Social Security Disability Income (SSDI)

    Please answer the following questions to determine possible eligibility for SSI or SSDI:
  • Is anyone in the family receiving counseling for mental health?
  • Is anyone in the family taking prescription medication for mental health?
  • Has anyone in the family ever been diagnosed with a mental health illness or a learning disability?
  • Does anyone display symptoms of a mental health illness, disability, or chronic health issue?
  • Does a chronic physical or mental ailment prevent any adult in the family from working?

  • Unemployment

    To qualify, clients must have earned at least $1,600 during a recent 12-month period known as the base period. They must have earned at least $440 outside of the base period quarter in which their earnings were the highest. They must either be entirely out of work or be working less than full time because no more work is available. Their unemployment must be involuntarily. They may be ineligible for unemployment if they quit their job voluntarily without good cause attributable to your employer; ,vere discharged for misconduct in connection with their work; were discharged for a felony or theft in connection with their work; or are out of work because of a labor dispute. If the client answered YES to both of these questions, they may be eligible for unemployment.
  • Is the client's unemployment involuntary?
  • If yes, did the client earn at least $1600 during the base period?

  • Benefit Screening Results

  • Date
     - -
  • Date
     - -
  • Should be Empty: