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  • CHFS Registration Form

    CHFS Registration Form

    Please Note: In order for your application to be considered, all required fields must be fully completed.
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  • Education

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  • Employment

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  • What is the total income earned in the previous years( 12 months) as shown on your IRS tax forms: $   
    This ONLY includes earned income (wages, salaries, tips, etc.). Report your actual earned income over

  • Vocational Interest

  • Household Details

  • Your Gross Household Income: $      
    Estimate household income for past 12 months.
    Only include wages/salaries/tips, business, interest/dividend, unemployment/disability, welfare assistance, alimony/child support, pension/retirement, regular gifts from non-household members & armed forces.

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  • CLIENT CONSENT FORM

    Note: Please complete this consent form if you are seeking our counseling services.
  • COUNSELING is a confidential process designed to help you address your concerns, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you and a trained counselor(not a therapist) who has the desire and willingness to help you accomplish your individual goals. Counseling involves sharing sensitive, personal, and private information that may at times be distressing. During the course of counseling, there may be periods of increased anxiety or confusion. The outcome of counseling is often positive; however, the level of satisfaction for any individual is not predictable. Your counselor is available to support you throughout the counseling process.

    CONFIDENTIALITY:

    All interactions with Counseling Services, including scheduling of or attendance at appointments, content of your sessions, progress in counseling, and your records are confidential.

    You may contact our office in writing that the counseling staff could release specific information about your counseling to persons you designate.

     

    EXCEPTIONS TO CONFIDENTIALITY:

    Since our counseling services is a multi-disciplinary in nature, the counseling staff works as a team. Your counselor may consult with other counseling staff to provide the best possible care. These consultations are for professional and training purposes.

    • If there is evidence of clear and imminent danger of harm to self and/or others, a counselor is legally required to report this information to the authorities responsible for ensuring safety.

     

    • The State of Florida law requires that any counseling services who learn of, or strongly suspect, physical or sexual abuse or neglect of any person under 18 years of age must report this information to the authority or child protective services.

     

    • A court order, issued by a judge, may require the Counseling Services staff to release information contained in records and/or require a counselor to testify in a court hearing.

    We appreciate prompt arrival for appointments. Please notify us at (850) 999-6610 if you will be late. Twenty-four hour notice of cancellation is required. This allows us to use the time for others.

    I have read and discussed the above information with my counselor. I understand the risks and benefits of counseling, the nature and limits of confidentiality, and what is expected of me as a client of the CHFS Counseling Services.

     

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  • Instruction

    Note: Please complete this form if you are seeking home safety improvement assistance.
  • To avoid any delays, please complete the  entire application and submit  with supporting documents.

    Eligibility Requirements:

    To be eligible for free home repairs, you must meet the minimum following requirements:

    • Property must be an owner-occupied single-family house, condominium or town home in Leon or surrounding Counties, but owner cannot have additional properties nor receive income from investment or rental properties.

    • Applicant have owned home for at least two years.

    • Applicant must be current with all local taxes, mortgage payments, homeowner association fees and assessments. (Not behind on payments!)

    • Homeowner's insurance. Proof of current homeowner's insurance WILL be required!

    • Applicant must not have a reverse mortgage or second mortgage. This also includes any other loans backed by your home.

    • SHIP Program: For the SHIP program, a resident of the home must be receiving disability (SSDI)

    • Mobile or manufactured homes are not eligible for this program.

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