840 Impact Cohort Intake Form

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Intake Form

840 Impact Inc
Please make sure to agree to our terms of service and note that all questions with an * must be answered or you will not be able to submit your form.
Today's Date:

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

Food & ShelterEmploymentSkills & TradesGED/EducationMentorshipMental Health & WellnessIntervention
Full Name*

PrefixFirst NameMiddle NameLast Name
D.O.B.*

MonthDayYear
Last four SSN#:*
Personal Phone:

Area CodePhone Number
Alternate Phone:

Area CodePhone Number
Physical Address:*

Street Address

Street Name, Lot / Apt. #

CityState

Zip Code
Homeless?
Mailing Address:

Street Address

Street Name, Lot / Apt. #

CityState

Zip Code
E-mail
Status:
Do you have Children at home?

YesNo
Total in Family:
Total in Household:
Have you been a resident of Cook County for 6 months or longer?

YesNo
Highschool Diploma/or equivalent *
Name of school
Employment
Most recent employer
Convicted of a felony

List Dates List Charges
Convicted of a misdemeanor

List Dates List Charges
Explanation of criminal history
Have you ever been part of any other youth programs ?

YesNo
If Yes, please fill out below. If No, leave blank.
Name of the program?*
INCOME/ASSETS EVALUATION
Are you willing to have someone to evaluate your needs and future career path?

YesNo
Appointment
Income & Expense evaluation section

Please type numbers only, this is for monthly income totals.

Household Members Income*

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

Household Members Expenses*

	Client's Amt.
Rent/Mortgage
Electricity/Gas(PG&E/MID)
Other Utilities(W/S/G)
Phone
Internet/Cable
Groceries/Food
Car Payment
Car Insurance
Credit Card/Loans
Eating Out/Movies
Toiletries (hygiene, etc.)
Haircuts/Beauty/Nails
Gas/Bus/Transportation
Health Insurance
Medical Bills/Prescriptions
Clothing, Shoes, etc.
Payday/Rent to own Loans
Education(books, supplies)
Child Support/Alimony

Total Household Member Income
Total Household Member Expenses
Income minus Expense Balance
If balance is a negative amount, please state how you make it work since you spend more than you make?
Who referred you? (Please be specific.)

First NameLast Name
Do they receive services through The 840 Impact Inc.

YesNo
Phone Number

Area CodePhone Number
Have you applied for any other programs?

YesNo
Name of Program:
What is the status?
Do you have a caseworker?

NoOther
Caseworker Name

First NameLast Name
Phone Number

Area CodePhone Number
May we Contact?

YesNo
ABOUT YOU
Please share a little bit about your current circumstances and what you want to get out of the program.
Interested Career Paths

CarpentryElectricPlumbingCommerical Driver License (CDL)Heating, Ventilation, & Air Conditioning (HVAC)Real EstateOther
Additional Information
Will your household size change in the next 3 months?

YesNo
THE 840 IMPACT INC. & it's partners provide classes in financial planning and literacy, homeownership, career development, employment counseling, job readiness, vocational skills, earn while you learn, computer training, and more. Would you like to know more about these opportunities?

YesNo
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Verification Documents

In order to verify the information you provided we will need proof of income and proof of residence. Verifications of income include copies of all forms of income in the household (SSI, Wages, Disability, Grants, TANF, etc.) Verifications of residence include your govermnet ID and or lease--this is required for intake verification. You can upload legible photos of the necessary documents below.
ID

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INCOME VERIFICATION

Upload a File

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LEASE

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INCOME VERIFICATION

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INCOME VERIFICATION

Upload a File

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What is something you’re grateful for today?*
We hope you have been encouraged by getting an opportunity to share your story. As we work with you over the next few days, we want to encourage you, believing that God values you and wants to improve your life.
Please sign to approve this document (click and hold mouse to draw signature, or with finger on mobile)
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Intake Form

INCOME/ASSETS EVALUATION

Income & Expense evaluation section

ABOUT YOU

Additional Information

Verification Documents

We hope you have been encouraged by getting an opportunity to share your story. As we work with you over the next few days, we want to encourage you, believing that God values you and wants to improve your life.