Enough|TODAY Recipient Intake Form

Recipient Intake Form

Enough|Today, Inc
What is something you’re grateful for today?*
All questions with an (*) must be answered or you will not be able to submit your form. Please be sure to sign and submit your intake form when done.
Have you received services from Enough|Today, Inc. in the past 3 years?*

YesNo
If Yes, What name did you apply with?
Today's Date:*

MonthDayYear
What is your specific need today? (Please only one and select the most urgent need.)*

1x1 MentoringLifestyle CoachingSelf-Confidence CoachingImage ConsultingCareer CoachingCareer Clothing'The Apt University' Scholarship
Full Name*

PrefixFirst NameMiddle NameLast Name
D.O.B.*

MonthDayYear
Personal Phone:*
Physical Address:*

Street Address

Street Name, Lot / Apt. #

CityState

Zip Code
E-mail*
example@example.com
Details About Need
Please share a little bit about the circumstances that led you Enough|Today, Inc.*
Enough|Today, Inc. provides classes in budgeting, nutrition & exercise, soft vocational skills and healthy relationships. Would you like to know more about these opportunities?

YesNo
Who referred you? (Please be specific.)

First NameLast Name
Do they recieve services through Enough|Today, Inc.

YesNo
Have you applied elsewhere for assistance?*

YesNo
Where Have You Applied:
What Happened?
Income & Expense evaluation section

Please type numbers only, this is for monthly income totals.
Does an agency assist you with your rent/mortgage?*

YesNo
If Yes, please fill out below. If No, leave blank.
What is the portion of rent they pay?
Total in Household:*
Status:*

Household Members Income*

	Your Income	Others Income
Food Stamps
Cash Aid
Disability
Vet's Disability
Other Grants
Medi-Cal/Medicare
WIC
Self-Employment
Wages(Net)
Unemployment
Social Security (Retirement)
Retirement/Pension
Veteran’s Retirement
Child Support/Alimony
Other

Total Household Member Income
Total Household Member Expenses
Income minus Expense Balance
Verification Documents

We will need proof of income to verify the information you've provided. Verification of income include copies of all forms of income in the household. Acceptable forms of verification include: Wages, SSI, Disability, Grants, TANF. Please upload the necessary documents below.

ATTENTION!

(PLEASE MARK OUT ALL PERSONAL INFORMATION SUCH AS SOCIAL SECURITY NUMBERS, BANK ACCOUNT INFORMATION, ETC. PRIOR TO SUBMITTING YOUR DOCUMENTATION)
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We look forward to hearing your story. As we work with you, our goal is to encourage you and to instill positive values to improve your life. Thank you for trusting and allowing Enough|Today, Inc. to be a part of your life journey!
Please sign to approve this document (click and hold mouse to draw signature, or with finger on mobile)
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Recipient Intake Form

Details About Need

Income & Expense evaluation section

Verification Documents

We will need proof of income to verify the information you've provided. Verification of income include copies of all forms of income in the household. Acceptable forms of verification include: Wages, SSI, Disability, Grants, TANF. Please upload the necessary documents below.

ATTENTION!

(PLEASE MARK OUT ALL PERSONAL INFORMATION SUCH AS SOCIAL SECURITY NUMBERS, BANK ACCOUNT INFORMATION, ETC. PRIOR TO SUBMITTING YOUR DOCUMENTATION)

We look forward to hearing your story. As we work with you, our goal is to encourage you and to instill positive values to improve your life. Thank you for trusting and allowing Enough|Today, Inc. to be a part of your life journey!