Client Application

Made Whole Program Intake Application

Thank you for your interest in the Made Whole program. Please fill out this application to help us understand your needs and eligibility. Your information will be kept confidential and used only to provide you with the best possible support.
Made Whole is a program created specifically to support single women with children. May we ask if you identify as a single woman/single home caregiver with children?*

Yes, I do.No, I don't.
Name*

First NameLast Name
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Direct Phone Number*
Alternate Number
Do you currently have Medi-Cal coverage?*

YesNoOther-pending
If yes, please provide your Medi-Cal group name (Ex. Anthem, Calviva, Kern Family, Calviva, Kaiser Ect):*
Are you currently getting regular help from any program, clinic, or organization that supports you with things like: finding resources,coordinating care,navigating appointments,check-in calls,home-based support, orongoing guidance?*

YesNoNot sure
Has your health plan or county assigned you someone who helps coordinate your care or checks in with you regularly?(ie Community Health Worker, Care Coordinator)*

YesNo
Have you ever been told you are enrolled in a health plan program that provides extra support for medical or life needs, sometimes called ‘Enhanced Care Management’ or ‘ECM’?*

YesNoNot Sure
Does anyone currently visit you at home or contact you regularly to help with health, appointments, or daily needs?*

YesNo
If answered yes or not sure to previous questions , who currently provides this support? (Check all that apply)

Health planDoctor’s office or clinicHospital programCommunity organizationHome-based programSomeone contacts me regularly, but I’m not sure whoI don’t know the name
If you know the name of the program or organization, please list it.
Notes(Optional):
If you begin receiving similar support from another program in the future, are you willing to let us know duplicate services?*

YesNo
I certify that I have answered these questions to the best of my knowledge. I understand that services may change if overlapping support is identified.*

I Agree
Best Availability :*

AM (9A-12P)AFN (12P-3P)PM (3P-6P)PM (6PM-9PM)
Date of Application*

MonthDayYear
Date
Consent and Privacy Statement
Your privacy is important to us. All information you provide is confidential and will only be used to determine eligibility and tailor our support services to your needs. We do not share your information with third parties without your consent except as required by law.

By submitting this application, you consent to receive communications from Made Whole to contact regarding program intake, updates and services.
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Made Whole Program Intake Application