CARE Complex Program Service In-take Form

CARE Complex Program Service In-take Form
Care Complex provides assistance to individuals who are employed or actively seeking employment. Priority will be given to those on the path to employment due to our mission and limited resources. Exceptions will be made in extenuating circumstances. The information you provide will help us tailor support to your specific needs and gather critical data for improving services.

Personal Information
Full Name*
Social Security Number
Date of Birth MMDDYYYY*

MonthDayYear
Date
Phone Number*
Email Address
example@example.com
Gender*
Race Ethnicity*

African AmericanCaucasianHispanic/LatinAsianNative AmericanOther
Marital Status*

SingleMarriedDivorcedWidowed
Preferred Language
Demographic Information
1. How long have you been experiencing homelessness?*

Not currently experiencing homelessnessLess than 6 months6 months - 1 year1-3 yearsOver 3 years
Where are you currently staying?*

ShelterTransitional HousingStreetsCar/VehicleCouch SurfingOther
Income and Employment Information
Are you currently employed?*

YesNo
(if yes) Job Title/ Position
Employer Name
Monthly Income
Hours per week
Do you receive any additional forms of income or benefits?*

YesNo
If yes, check all that apply:

SNAPSSI/SSDIUnemployment BenefitsChild SupportOther
Health and Support Information
Do you have any medical conditions or disabilities that affect your ability to work or live independently?*

YesNo
If yes please explain
Do you have health insurance?*

YesNo
If yes, indicate the type:

MedicaidMedicarePrivate InsuranceOther
Name of the Insurance Provider
Program Participation and Goals
What are your primary goals in joining the Care Complex Program? (Select all that apply)*

Homeless 2 Home (Rental Assistance)Community Table (Meals)Mail ServicesLocker StorageInternet & Phone AccessGrooming & Hygiene Services (Shower Truck)Bus PassesStep Into Success (Resume & Career Assistance)Interview Clothing
Please upload your identification. Anyone requesting bus passes must also upload a current work schedule provided by their employer.*

To participate in H2H, receive mail, access bus passes, or obtain a locker, you must upload a valid photo ID. If you do not have an ID, you may upload your Clarity Card instead. If you have neither, you will only be eligible for limited services.
Cancelof
Household Information
Do you have children or dependants*

YesNo
If yes how many
Ages of Dependents (select all that apply)

0-56-1213-18Over 18
Do you need assistance with child care?

YesNo
Applicant Signature

I certify that all the information provided in this application is true and accurate to the best of my knowledge. For any questions, please contact us at careinfo@carecomplex.org
Signature*

Clear
Date*

MonthDayYear
Date
This information will be used for program reporting and statistics, ensuring we can continue to offer effective solutions for our community.
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