Client Information & Request for Services

Client Information & Request for Services

Please fill out honestly & completely to the best of your ability in order for us to be able to assist you.
Name*

First NameLast Name
Date of Birth
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Work Phone Number *
Please enter a valid phone number.
Emergency Contact/Relationship & Phone Number *
Employer*
Hourly Pay*
How often paid? *
How long employed? *
Do you belong to a local church?*

YesNo
If yes, where do you attend?
Are you receiving any other assistance? (SNAP, Medicaid, TANF, SSI, etc.) please list below: (If you do not receive any of the mentioned and need to apply, please mention if so and which one)*
Are you receiving/paying child support? Please explain the current status: *

Please list the names, relationship and ages of all household members *

	Name	Age	Relationship
1
2
3
4
5
6
7

What type of assistance are you seeking? (Please be as detailed as possible).*
What solutions have you come up with to help your situation? *
Do you have permanent housing?*

YesNo
What actions have you taken? *
What do you hope to gain from this experience? *
Are you currently invloved in a domestic situation or are you in fear of you/children's lives? If yes, please explain in detail. *
Expenses

What are your current expenses?
Do you pay rent or mortgage?*

RentMortgage
How much? *

Are your current expenses paid up to date? *

	Y/N	How Much	Due Date
Gas
Electric
Water
Childcare
Other

Clothing needs (please complete items needed and fill in size)

	Y/N	Size
Shirts
Pants
Undergarments
Socks
Other items

How will receiving our assistance change your life going forward? *
How will this assistance make you feel? *
Would you recommend this program to other single parents? Why or why not? *
Please list other needs below
Do you have any medical issues or concerns we should take into consideration? (If so, can you provide documentation for this?)*
****Please understand out of respect, safety, and privacy, we keep all our client's information confidential. We do not release any personal documentation to anyone without permission from our client. However, under reasons of self-harm, harm to others, unlawful or signs of behavior that would be considered abuse, illegal or unsafe, such agreement will be waived and we are mandated to report such information to agencies applicable.
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Client's Agreement
I confirm that all of the above information is correct and truthful to the best of my knowledge. I understand that I may be denied services if there is any abuse or deceit in receiving or applying for services through Working for a Purpose Foundation or its staff.
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Please prepare to submit the follwoing documentation when applicaiton is complete:
- Valid GA Identification or GA driver's license
- Utility bill or documement showing proof of residence and account status
- Documentation of recipient of state assistance or applicaiton process
Working for a Purpose Foundation does not and shall not discriminate on the basis of race, color, religion (creed) gender, expression, age, national orgin (ancestry), disablity, sexual orientation, or military status, in any of its activities or operations.

As a client of Working for a Purpose Foundation, you have the following rights regarding the confidentiality of yoru personal information and communications with WFAP's staff and volunteers:
1. The information that you provide to WFAP will be kept confidential to the greatest extent allowed by law.
2. You may choose what infomration you want to provide to WFAP as long as true and to the best knowledge.
3. In accordance with the organization requirements, to be approved for services you must be of non married status and single parent (guardian) head of househould. Proper documentation may be needed for such proof.
4. The information that you provide to WFAP may be required by law to report certain situations even if you don't give them permission to share or report the situations, such as suspected child abuse or neglect, threat to self and/or others. A mandated staff member of WAFP will inform you of any reporting requirements prior to converstations and will tell you when they must make a report and what information will be shared. Even when these reports are made, WFAP will not share infromation beyond what is required by law.
5. Some general information about the types of services provided and overall demogrpahics (e.g. age and income ranges, average number of children, ethnicities) of people that recieve WFAP services musbt be shared with eth agencies that fund or support WFAP. However information that specifically could identify you as someone who receives WFAP services, will never be shared unless speficially authorized in writing by you.
6. With your permission, we may inquire an opportunity to share your story/photo on social media and/or our organization's website as a testimony for our community supporters, other potential clients and program followers This would be utilized only to provide insight on what services we offer, how we are able to assist you and other likeminded individuals. If you hsould want to opt out of that, it does not disqualify or discriminate you from receiving our services. If at some point you should decided to withdraw from, no longer need, are terminated from our porgram, or change your status for that agreeement, WFAP would need to be notified in writing upon such occasion for us to suspend further use of your story/photo.
7. After your intake/initial interview with WFAP, you may be referred to other agencies for additional help and support. Agencies we partner with include, but are not limited to Union Mission, Family Promise, Family Connection, United Way, Gateway Behavioral Health, After the Rain, Ready 2 Connect, Effingham County Victem Witness Assistance, DFACS, Georgia Legal Services, Safe Haven Women's Shelter.
  
  You can decide how much or how little of your personal infomration will or will not be shared with each partner agency. Note: the amount of information you do or do not share can affect the aopportunity to help you at he fullest capacity by WFAP or other affilated agencies. You will be told in general what each partner's/agencies obligations are to keep your information confidential. If you should choose to have WFAP share some or all of your information, you will be told exaclty how much and what information will be shared and the purose of such.
8. If you have any questions or concerns about any of the above stated or your rights within the use of WFAP organization, please contact Working for a Purpose Foundation at 912-712-6911
I First Name* Last Name* have received and understand my rights to confidentiality.
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I understand that the Working for a Purpose Foundation has an obligation to keep my personal information, and my records confidential. I also understand that I can choose to allow WFAP to release some of my personal informatin to certain individuals and agencies.
I, First Name Last Name , do not authorize Working for a Purpose Foundation to share my information with the following individuals/agencies:
Please list the names/agencies you do not authorize.
I understand:

That I do not have to sign a release form. I do not have to allow WFAP to share my information. Signing a release form is completely voluntary. Initials *

That releasing information about me could give another agency or person information about my location and would confirm I have been receiving services from WFAP.   Initials*

That WFAP and I may not be able to control what happens to my information once it has been released to an allowed person or agency, and that the agency or person receiving my information may be required by law or practice to share it with other necessary parties.   Initials *

This release expires: until further notice, program termination or withdrawal.
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Client Information & Request for Services

Expenses

Client's Agreement