Emergency Basic Needs Program Application

	Enter Amount
Rent/Mortgage
Renter's or Homeowners Insurance
Utilities (water, electric, gas)
Internet, Cable, and Phones
Other housing like property taxes
Groceries and household supplies
Meals out
Other food expenses
Public transportation, Uber, Taxi's
Gas for car
Parking and tolls
Car insurance
Car maintenance
Car loan payment
Other transportation expenses
Medicines
Health Insurance
Other medical (doctor appointments, eyeglasses)
Childcare
Child support paid
Clothing/Shoes
Money given to family
Laundry/Dry cleaning
Donations
Entertainment (movies, amusement parks etc.)
Other personal expenses like hair and nails
Fees for cashier's checks, money order or transfers
Prepaid cards or phone cards
Bank of credit card fees
Other fees paid
School costs
Other payments (like credit cards and savings)
Other expenses this month

Consent Form

Emergency Basic Needs Assistance Program
The Emergency Basic Needs Assistance Program, provided by Healthy Mothers Healthy Babies Coalition of Broward County, Inc. has been explained to me.

By signing below I understand and agree to the terms of the Emergency Basic Needs Assistance Program. I give permission to release all information obtained by the Emergency Basic Needs Assistance Program staff to funders or other providers for the purpose of case management, referrals, and linkages to other services.

I authorize staff to contact any other parties which may be necessary to assist with the provision of financial assistance.
Participant Name:*

First NameLast Name
Participant Signature:*

Clear
Date:*

MonthDayYear
Date
EBN Staff Name:

First NameLast Name
Staff Signature:

Clear
Date:

MonthDayYear
Date

Participant Rights and Responsibilities

Emergency Basic Needs Assistance Program
The Emergency Basic Needs Assistance Program is a low income, temporary assistance program for Broward County families who meet the eligibility income requirements for emergency food, utility payment and vouchers for basic needs, such as bus passes, gas cards, diapers or hygiene products.
As a client you have a right to.......................
- Receive considerate and respectful service at all times
- Participate in the development of the plan of service; receive an explanation of any services proposed, and alternative services that may be available
- Refuse services without fear of reprisal or discrimination
- Know that all communications and records will be treated confidentially and that no information will be given out without a written release
- Receive a copy of the grievance procedure
- Access to an interpreter if needed
Participants have the responsibility to....................
- Notify the agency of changes in their contact information or financial situation
- Provide required documentation within the given timeframes
- Keep appointments and notify the agency if unable to do so
- Complete required Pre & Post surveys for program
- Advise the agency of any problems or dissatisfaction with the service.
Participant Name:*

First NameLast Name
Participant Signature:*

Clear
Date:*

MonthDayYear
Date
EBN Staff Name:

First NameLast Name
Staff Signature:

Clear
Date:

MonthDayYear
Date

Self-Sufficiency Matrix

Emergency Basic Needs Assistance Program
Initial AssessmentExit Assessment
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Review the statements for each heading below. Please choose the best response that relates to your CURRENT status.
Mobility:*
Food:*
Life Skills:*

	Completely	Very Well	Somewhat	Very Little	Not at all
I could handle a major unexpected expense
I am securing my financial future
Because of my money situation, I feel like I will never have the things I want in life.
I can enjoy life because of the way I'm managing my money
I am just getting by financially
I am concerned that the money I have or will save won't last

	Always	Often	Sometimes	Rarely	Never
Giving a gift for a wedding, birthday or other occasion would put a strain on my finances for the month
I have money left over at the end of the month
I am behind with my finances
My finances control my life

Emergency Basic Needs Program