Gather n Grace Intake Assessment
Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
Date
Phone:
Format: (000) 000-0000.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
example@example.com
Marital status:
# of children:
Ages of children:
Place of employment:
Supervisor:
Contact #:
If requested, could you pass a drug test
yes
no
Do you have any warrants out for your arrest?
yes
no
If yes, explain
Have you been incarcerated?
yes
no
If yes, explain
What type of assistance are you requesting:
Housing
Food
Utilities
Transportation
Childcare
Other
If you checked any of the above, describe current need and circumstances:
What type of assistance have you or are you receiving? (food stamps, WIC, etc)
Goals - short and long term (job, interview, housing, etc):
Spiritual/Emotional needs & resources How can we help and/or pray for you?
Do you regularly attend Monday night family dinner at Fireman's Park?
yes
no
How did you hear about us?
Back
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Gather n Grace Giving Agreement
Our Mission is to intentionally assist, empower, encourage, support and equip
others to be His best for their lives
To create a welcoming place where chains are broken, healing happens, and
divine encounters occur
With our mission as our focus, we seek God's guidance first and we are
intentional in the assistance we provide.
If aid is given directly to me, via gift card or otherwise, I agree to use
the funds as intended and allocated.
I understand that support is temporary and limited.
All forms of assistance are recorded in Gather n Grace's records.
Maintaining responsibility and accountability is important as we assess
all current and future requests and needs.
Signature
Date
-
Month
-
Day
Year
Date
Gather n Grace
Date
-
Month
-
Day
Year
Date
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