Client Intake Form

NOTE: Submitting an application and supporting documentation does NOT guarantee financial assistance. This is dependent on current needs and available funds.
Date of Intake*

MonthDayYear
Date
Email*
example@example.com
Last*
First*
Middle Initial*
Date of Birth*

MonthDayYear
Date
Social Security Number*
CURRENT ADDRESS AND INFORMATION

(Verification may be required)
Street*
City*
State*
Zip Code*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
MaleFemale
Gender - Other:
SingleMarriedDivorcedWidow(er)
Native AmericanAsian AmericanBlackHispanicWhite
Race - Other:
MedicareMedicaid
YesNo
YesNo
Year Disabled
PhysicalMentalDevelopmentalSubstanceDVSAIDS/HIV
YesNo
Where are you staying?
EMPLOYMENT INFORMATION

HOUSEHOLD INFORMATION
Number of adults in the household including you
Number of children in the household

Please explain circumstances/need/situation
Source of Income/Assistance - Amount Received Each Month
Wages: $
SS Disability: $
Social Security: $
Unemployment: $
Child Support: $
Retirement: $
Alimony: $
TANF: $
VA Benefits: $
SNAP: $
WIC: $
Other Source:
YesNo
WaterElectricGasOther
Monthly Total of Household Income (not including Food Stamps or WIC): $
Housing: $
OwnGISMortgage StatementRentLeaseLandlord Statement
Landlord Name
Landlord Phone
Format: (000) 000-0000.
Intake Completed By: (Select One: PCC Employee/Client/PCC Intern/PCC Volunteer/Client Advocate
Date

MonthDayYear
Date
Presbyterian Community Center 1228 Jamison Ave, SE Roanoke, VA 24013 540.982.2911
Privacy Notice and Release

The Privacy Act of 1974 requires that when the Presbyterian Community Center (PCC) asks you for information we tell you our legal right to ask for the information, why we are asking you for it, and how it will be used. We must also tell you what could happen if we do not receive it and whether your response is voluntary, required to obtain a benefit, or mandatory. Under federal law, private individuals are under no legal obligation to provide private information to non- profit service organizations. Providing personal information is voluntary, and with the purpose of facilitating assistance and support services to you. If you do not provide requested information, this could impede or prevent us from providing you such assistance. We do not sell the information we collect. The information that you provide will be used by the PCC to coordinate with outside sources to provide you with emergency financial, nutritional, educational, and informational assistance.

We use various outside sources to provide these services, including (but not limited to) churches, Social Service Agencies, non-profit organizations, employers, and landlords or Property Management Agencies.
I acknowledge the above privacy notice. All information provided is true and honest to the best of my knowledge.
Signature*
Date*

MonthDayYear
Date
I, _________________________________, do authorize the Presbyterian Community Center (PCC) to release and discuss my personal information with necessary outside agencies for the purpose of coordinating assistance and services. These outside agencies include, but are not limited to (please see below): *

First NameLast Name
- Churches
- Social Service Agencies
- Non-Proft Organizations
- Employers
- Landlords/Property Management Agencies
- Utility Companies
This release is valid for the period of three years and expires on _________________. I acknowledge I have the right to revoke this authorization at any time, and will provide that request in writing.*

MonthDayYear
Date
Signature*
Date*

MonthDayYear
Date
PCC Employee
What is 3 Years from Today's Date?

MonthDayYear
Date

⚠️ Thank you for taking the time to complete the intake form.
At this time, based on your responses, you do not meet the current eligibility criteria for assistance through the Presbyterian Community Center.

Please know that this does not mean you're alone. There are several other community resources that may be able to assist you:

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Gracias por tomarse el tiempo para completar el formulario de solicitud.

En este momento, según sus respuestas, no cumple con los criterios de elegibilidad para recibir asistencia a través del Centro Comunitario Presbiteriano.

Queremos que sepa que no está solo/a. Existen otros recursos comunitarios que podrían brindarle ayuda:

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

RAM House: (540) 981-173

The Salvation Army: (540) 343-5335

Central Intake: (540) 853-1322

Get Help with 2-1-1 Virginia: Visit 211virginia.org or dial 2-1-1

We encourage you to reach out to one of these organizations.

Les animamos a que se pongan en contacto con una de estas organizaciones.
Should be Empty:

Rows	Employer	Rate of Pay	Full or Part Time	Weekly, Monthly, or Bi-Weekly
Job #1
Job #2
Job #3
Job #4
Job #5
Job #6

Rows	Name	Date of Birth	Relationship	Social Security Number	Employment
Member #1
Member #2
Member #3
Member #4
Member #5
Member #6

Presbyterian Community Center Client Intake Form

CURRENT ADDRESS AND INFORMATION

EMPLOYMENT INFORMATION

HOUSEHOLD INFORMATION

Source of Income/Assistance - Amount Received Each Month

Presbyterian Community Center 1228 Jamison Ave, SE Roanoke, VA 24013 540.982.2911