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Client Intake Application
Complete this form to help us assess your supportive housing and employment service needs. Provide as many details and documents as possible.
Supportive Housing Options (check all that apply)
Emergency Shelter
Transitional Housing
Permanent Supportive Housing
Rapid Re-Housing
Staying with Family/Friends
Renting / Own Home
Other
Employment & Pre-Employment Services (check all that apply)
Supportive Employment
Pre-employment Services
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Provider One #
*
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Monthly Income
Income Source (check all that apply)
TANF
SSI
HEN
ABD
NONE
Other
Eligibility Verification (check all that apply)
Photo ID
ProviderOne Card
Health Insurance Card
Other
ID Card-File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
ID Card- Take Photo
Provider One Card-File Upload or Take Photo Below
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Provider One Card - Take Photo
Health Insurance Card-File Upload or Take Photo Below
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Health Insurance Card-Take Photo
Have you ever been incarcerated?
Yes
No
Are you currently on probation or parole?
Yes
No
Have you ever been convicted of selling and/or Manufacturing Methamphetamine?
*
Yes
No
Have you been convicted of any sexual offense?
Yes
No
Program Goals & Support Needed
WRITE THIS NUMBER DOWN & FOLLOW UP ON YOUR APPLICATION BY CALLING 253-212-2264
HARRIET TUBMAN FOUNDATION FOR SAFE PASSAGE
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Harriet Tubman FoundationHIPAA Privacy Consent Form. This form explains how your health information may be used and disclosed by the Harriet Tubman Foundation For Safe Passage (HTFFSP) and how you can access this information. Please read it carefully and ask any questions before signing. By signing this form, you authorize HTF to use and disclose your Protected Health Information (PHI) for the following purposes: 1. Treatment: Coordination of care among healthcare and supportive service providers. 2. Payment: Billing for services provided by HTFFSP and its partners. 3. Healthcare Operations: Quality improvement, training, audits, and program compliance reviews. Your information will not be shared for other purposes without your written consent unless required by law. You have the right to revoke this consent at any time in writing, except to the extent that action has already been taken based on your authorization. Your Rights:- You may request restrictions on how your PHI is used or disclosed.- You may request a copy of your records.- You may request an amendment to your records if you believe there are errors.- You will be notified in case of any breach involving your PHI.
*
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