PKCC New Client Request
Personal Information
Name
*
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Decline to Answer
Other
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race/Ethnicity
*
African
African American/Black
American Indian/Alaskan Native
Asian (Not Cambodian)
Brazilian or Portuguese
Cambodian
White/Caucasian
Middle Eastern
Biracial
Decline to Answer
Other
Health Insurance
MassHealth
Private Insurance
Other
Language (Primary)
English
French
Khmer
Portuguese
Spanish
Other
Language (Secondary)
English
French
Khmer
Portuguese
Spanish
Other
Do you have an ID, birth certificate, etc.?
Please Select
Yes
No
Decline to Answer
If no, would you like assistance to obtain these documents?
Please Select
Yes
No
Decline to Answer
Total in Household
Please include yourself in the count.
# of Adults (18-64)
*
# of Children (Under 18)
*
Please enter 0 if not applicable
# of Seniors (65+)
*
Please enter 0 if not applicable
Family Member Information (Name, Relationship, DOB, Gender):
*
Please enter N/A if not applicable.
Is anyone in your household a veteran?
Yes
No
Is anyone in your household disabled?
Yes
No
Is anyone in your household part of the LGBTQ+ community?
Yes
No
Emergency Contact Information
Name
First Name
Last Name
Phone Number
Relationship
What can we assist you with? (Select all that apply)
*
Food
Clothing
Diapers/Baby Essentials
Personal Hygiene Items
Residential Housing (Youth)
Housing
Vital Documents
Wish Project Referral
Mental Health Support
Family Support
Recovery Support
Financial Support
Other
Submit
Should be Empty: