Prevention & Diversion Intake Form
Head of Household Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Last four of Social Security Number
*
Ethnicity
Please Select
Hispanic or Latino
Not Hispanic or Latino
Race
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or More Races
Gender
Please Select
Male
Female
Other
Prefer not to answer
Are you a Veteran?
Yes
No
Primary Language
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at this address?
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Household Members
Current Housing Type
Rent
Own
Staying with friends/family
Hotel
Shelter
Other
Monthly Household Income (approximately)
Source(s) of Income/Employer
Do you receive any non-cash benifets?
EBT/SNAP
WIC
Section 8
TANF
Other
Health Insurance
Medicaid
Medicare
Private
Other
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Briefly explain how you need our services or what led to your current situation
*
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Landlord Information
Amount required to get you back in good standing with your Landlord or Property Management
Current Monthly Rent
Landlord or Property Management Name
Landlord or Property Management Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Landlord of Property Manager Email
example@example.com
Landlord or Property Management Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Consent to Contact
I give permission for Mel Trotter to contact me about services and to share my referral information with partner agencies as needed to coordinate assistance.
*
I agree
Signature
*
Todays Date
*
/
Month
/
Day
Year
Date
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Are you filling this form out for yourself or for someone else?
*
For myself
Someone Else
Referring Organization Information
Organization Name
Contact Person
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred method of follow-up
Phone
Email
Other
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Submit
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