CHIPPEWA-LUCE-MACKINAC COMMUNITY ACTION AGENCY
CLIENT INTAKE & CONSENT FORM
Date:
Name:
DOB:
Social Security #:
Gender:
Mailing Address:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Are you or have you Experienced Homelessness:
Currently
1 Month
2 Months
3
Month
Other
HOW CAN WE HELP YOU TODAY?
Homelessness/Emergency Shelter
Rental Assistance
Utility Deposit
Housing Information/Landlord List
Eviction Notice
Utility/Shut-Off Notice
Help with Housing Applications
Anyone a Veteran?
Yes
No
Anyone pregnant?
Yes
No
Are you currently Fleeing or Experiencing Domestic Violence?
Yes
No
Rows
Name
Relationship to HOH
Social Security No.
Gender
DOB
Race/Ethnicity
1
2
3
4
5
6
Race/Ethnicity
Native American or Alaska Native
Asian American
White
Native Hawaiian/Other Pacific Islander
Hisoanic or Latino
Race/Ethnicity
Type option 1
Type option 2
Type option 3
Type option 4
Type option 5
Type option 6
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Consent to Disclose Release of Information
Client's Name
Date of Birth
I hereby give consent and authorize the following agencies to reciprocate information to and with:
Chippewa-Luce-Mackinac Community Action Agency
510 Ashmun Street, Sault Ste. Marie, MI 49783
P: (906)632-3363 F: (906)632-4255
Please check all agencies that are NOT permitted to reciprocate information.
Agency's
Chippewa County Health Department
Chippewa County Health Department
EUP Dispute Resolutions Center
EUP Dispute Resolutions Center
Sault Housing Commission
Sault Housing Commission
Norther Transitions Incorporated
Norther Transitions Incorporated
Dept of Health and Human Services
Department of Health and Human Services
Salvation Army
Salvation Army
Hiawatha Behavioral Health
Hiawatha Behavioral Health
Diane Peppler Resource Center
Diane Peppler Resource Center
Great Lakes Recovery Center
Great Lakes Recovery Center
United Way of the EUP
United Way of the EUP
Sault Tribe of Chippewa Indians
Sault Tribe of Chippewa Indians
West Bridge Apartments
West Bridge Apartments
Michigan Works
Michigan Works
Veteran Services
Veteran Services
MI Rehabilitation Service
MI Rehabilitation Service
Bay Mills Indian Community
Bay Mills Indian Community
The purpose of this Consent is to Disclose / Release of Information is to assist with housing / homeless related issues including behavioral. I (we) understand that I (we) cannot be denied assistance if we refuse to sign.
To revoke this Consent, it must be in writing prior to the expiration of
Today's Date:
Client's Signature
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