Appointment Form
To schedule an appointment, please fill out the information below.
Appointment Details
Contact Information
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Best method for contacting you?
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Email
Phone
Best time of day to reach you?
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Morning
Noon
Afternoon
Evening
Night
ADDRESS WHERE YOU RECEIVE MAIL.
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ARE YOU CURRENTLY HOMELESS?
*
YES
NO
DO YOU CURRENTLY HAVE HEALTH INSURANCE? MEDICAID, MEDICARE OR PRIVATE?
*
YES
NO
ARE YOU A VETERAN OF THE UNITED STATES ARMED FORCES OR FIRST RESPONDER?
*
YES
NO
HAVE YOU BEEN CONVICTED OF A FELONY OR MISDEMEANOR
*
YES
NO
IF YES PLEASE LIST CONVICTION DATE, COUNTY AND STATE, AND DETAILS OF PROBATION OR PAROLE.
How can we assist you today?
*
HOUSING APPLICATION
MEDICAID APPLICATION
SNAP/FOOD STAMPS APPLICATION
SSI SCREENING
EXPUNGEMENT ELIGIBLITY
DIVORCE WITH NO CHILDREN
UNEMPLOYMENT APPLICATION
CAREER DEVELOPMENT: JOB APPLICATION, RESUME WRITING, JOB READY CLOTHING
GOVERNMENT PHONE APPLICATION
DOMESTIC VIOLENCE SUPPORT
Other
PLEASE GIVE A DETAILED DESCRIPTION OF YOUR SITUATION. ONE LINE SENTENCES WILL NOT MOVE APPLICATION FORWARD.
*
PLEASE EXPLAN WHAT STEPS YOU HAVE TAKEN TO HELP YOUR SITUATION THUS FAR.
*
PLEASE UPLOAD A COPY OF YOUR PHOTO ID AND HEALTH INSURANCE IF AVAILABLE.
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PLEASE REVIEW OUR CONSUMER HANDBOOK WITH POLICIES AND PROCEDURES.
Signature: BY SIGNING BELOW, YOU ATTEST THAT YOU HAVE READ AND UNDERSTAND OUR POLICIES AND PROCEDURES AND AGREE TO OUR SERVCIES.
*
Printed Name:
*
Date
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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