DCM Case Assessment Form

Name:*

First NameLast Name

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:*

Please enter a valid phone number.

By checking this box, you agree to receive TEXT messages from PLUM Foundation related to conversational messages at the phone number provided above. You may reply STOP to opt-out at any time. For assistance, reply HELP. Messages and data rates may apply. Message frequency will vary. Learn more on our https://www.plumarkansas.org/privacy-policy Privacy Policy Page.*

Birthdate*

Last 4 Digits of Social Security:*

Martial Status:*

SingleMarriedSeparated

Gender (F-Female, M-Male)*

Ethnicity:*

How many Dependents do you have? *

Income Level:*

>25,00025,000-50,00050,000-75,00075,000 <

Do you have health insurance?*

YesNo

Do you receive any assistance listed below?*

What Assistance is Needed?*

What would you say is your current mental status? Is Assistance Needed?*

Have you applied for any services from the following?*

If other services, what are they?*

Do you have money in your savings?*

Are you currently employed? If not, how long have you been unemployed?*

What is your monthly Revenue? List all money you receive monthly, including the amount and source of income. please be as truthful as possible, this will help process your application faster. We will need documentation of monthly reveneue *

What is your monthly Expense? List all monthly expense, including the amount and source of expense. please be as truthful as possible, you may be asked to produce documentation of monthly expense.*

Did you become unemployed due to the Disaster ?*

Do you currently have housing? If so, are you renting or buying?*

Do you have homeowners insurance or rental insurance? If so what company?*

How has this Disaster Impacted your life? Please give some examples.*

How could recovery efforts be better for you? Please give some examples.*

Do you feel your Ethnicity, Gender, Age, or Health Condition impacted how you were able to recover ? If so please list examples.*

By signing your full legal name, you agree not to consider participating in this program, and the information given to be an invitation for any doctor-client relationship. The information does not convey medical, legal, accounting, tax, career or other professional advice of any kind. You should not rely on the information as medical advice for any purpose as it may not reflect current research or developments. No person should act or refrain from acting on the basis of information given to them during any conversation or interactions with this program or its staff and team. Information should not be relied upon or used as a substitute for consultation with professional medical advisors. PLUM Foundation, associates, officers, board members, staff and main organization expressly disclaims all liability in respect to actions taken or not taken based on any contents of information given. By signing your name, you agree to this disclaimer and waive any and all liability claim against PLUM Foundation, associates, officers, board members, and associates of any harm or damage done. All content found on our website, course, services, coaching sessions including text, images, audio, or other formats are created for informational purposes. The content is not intended to be substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you read, hear, or receive from our program. If you think you may have a medical emergency, call your doctor, go to the emergency department, or call 911 immediately. PLUM does not recommend or endorse any specific tests, physicians, products procedures, opinions, or other information that may be mentioned on our website, brochures, or flyers. Reliance on any information provided by PLUM foundation, PLUM employees, contracted writers, health coaches or medical professionals presenting content for publication to PLUM Foundation at your own risk. The site, course, sessions, may contain health or medical related materials or discussions regarding sexually explicit diseases, and medical conditions. Not any of these materials are intended to be offensive. The information given during the program and its content are provided on an "as is" basis. Links or resources to additional educational resources and content not created by PLUM Foundation are taken at your own risk. PLUM Foundation is not responsible for the claims of any external websites, and other educational research or resources. By enrolling into this program, you agree that you are not currently receiving assistance from any other Diaster Case Management (DCM) organization, and that we are working with you exculsively as a client. You also agree to the terms that you are only allowed to work with one diaster case management at a time, and to disclose whether have received assistance from any other agency.

Please Sign:*

Disaster Case Assessment Application