CHIPPEWA-LUCE-MACKINAC COMMUNITY ACTION AGENCY
CLIENT ASSESSMENT
Head of Household:
Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
Date
Social Security #:
Sex:
Male
Female
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Race/Ethnicity:
American Indian or Alaska Native
Asian American
Black or African American
Caucasian
Native Hawaiian/Other Pacific Islander
Hispanic or Latino
Is anyone in the household a Veteran?
Yes
No
Are you Disabled?
Yes
No
Who?
Anyone Pregnant?
Yes
No
Who?
Are you currently fleeing and/or experiencing Domestic Violence?
Yes
No
Have you Experienced Dometic Violence?
Yes
No
How Long Ago?
Are you currently experiencing Homelessness?
Yes
No
Where did you sleep last night?
Before that??
Are you currently Employed?
Yes
No
Who?
Income Per Month?
HOW CAN WE HELP YOU TODAY?
Please tell us why you are here?
Household Members:
Name
Relationship to HOH
Social Security Number
Sex
Date of Birth
Race:
Name
Relationship to HOH
Social Security Number
Sex
DOB
Race:
Name
Relationship to HOH
Social Security Number
Sex
DOB
Race:
Name
Relationship to HOH
Social Security Number
Sex
DOB
Race:
Name
Relationship to HOH
Social Security Number
Sex
DOB
Race:
Name
Relationship to HOH
Social Security Number
Sex
DOB
Race:
Name
Relationship to HOH
Social Security Number
Sex
DOB
Race:
Consent to Disclose Release of Information
Client's Name
Date of Birth
-
Month
-
Day
Year
Date
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.
Agencies
Chippewa County Health Dept.
Chippewa County Health Dept.
EUP Dispute Resolutions Center
EUP Dispute Resolutions Center
Sault Housing Commission
Sault Housing Commission
Northern Transitions Incorporated
Norther Transitions Incorporated
Dept of Health and Human Services
Dept of Health and Human Services
Salvation Army
Salvation Army
Hiawatha Behavioral Health
Hiawatha Behavioral Health
Diane Peppler Resource Center
Diane Peppler Resource Center
Sault Tribe of Chippewa Indians
Sault Tribe of Chippewa Indians
West Bridge Apartments
West Bridge Apartments
Great Lakes Recovery Center
Great Lakes Recovery Center
United Way of the EUP
United Way of the EUP
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:
-
Month
-
Day
Year
Date
Client's Signature
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