Client Intake & Presurvey Form
Welcome to the Golden Resources Connections Program: Connecting Seniors to Stability, Support, and Security.
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Contact Method
*
Phone
Email
Mail
Section 2: Eligibility Verification
Applicant must be a resident of Pinellas County, 55+
Are you a resident of Pinellas County?
*
Yes
No
Are you 55 years of age or older?
*
Yes
No
Are you the primary utility account holder?
*
Yes
No
Do you have overdue utility bills or need immediate assistance (electricity, gas, water)?
*
Yes
No
What is your total ANNUAL household income?
*
Under $21,870
$29,580 - $21,869
$37,290 - $29,579
$45,00 - $37,289
$52,710 - $44,999
$60,420 - $52,709
$68,130 - $60,419
$75,840 - $68,129
What is your HOUSEHOLD SIZE?
*
1
2
3
4
5
6
7
Section 3: Pre-Survey Questions
Have you received a utility shutoff notice in the last 30 days?
*
Yes
No
On a scale of 1 to 5, how confident do you feel managing your monthly expenses?
*
1 - Not Confident
2
3
4
5 - Very Confident
On a scale of 1 to 5, how stressed or anxious do you feel about your current financial situation?
*
1 - Not stress
2
3
4
5 - Very Stressful
Would you like a legacy kit to document important personal and family information (e.g., Financial Power of Attorney, Last Will & Testament, Medical Power of Attorney, Medical Directive)?
*
Yes
No
How did you hear about the Golden Resource Connections Program?
Please be specific.
Section 4: Documentation
Please attach a copy of your most recent utility bill or shut-off notice (dated within the last 30 days).
File Upload
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Section 5: Schedule Your Follow-up Appointment
Choose the next available date and time that works for you.
What date and time work best for you?
Any other specific date and time, if the above selection is not suitable.
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Would you like to be notified about promotional services?
*
Yes
No
Section 6: Consent & Signature
By clicking signing my name below and clicking SUBMIT, I confirm that the information provided is accurate to the best of my knowledge. I understand that assistance from the Golden Resource Connections Program is based on eligibility and available funding.
Name
*
First Name
Last Name
Submit
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