Housing Enhancement
for Lower Income People

HOW MAY WE HELP YOU?
Please check all the appropriate below:
   Food:  Housing:  Employment:  Utilities:  Other:

   Name:    MALE:  FEMALE:

   SOCIAL SECURITY #:  RACE:  DOB:

   DL #: DATE ISSUED: DATE EXPIRES:

   CURRENT ADDRESS:
  HOME PHONE :

   PREVIOUS ADDRESS:

PLEASE GIVE THE FOLLOWING INFORMATION FOR EVERYONE IN YOUR HOUSEHOLD:

EMPLOYMENT

   WHERE DO YOU WORK?:

   ADDRESS:
  WORK PHONE:

   HOW LONG HAVE YOU WORKED THERE?:

   HOW ARE YOU PAID?   WEEKLY:  BI-WEEKLY:

MILITARY SERVICE

   HAVE YOU EVER SERVED IN THE MILITARY?   YES:      NO:

   BRANCH:    LENGTH OF SERVICE:

   TYPE OF DISCHARGE:

TRANSPORTATION/INCOME

   DO YOU HAAVE DEPENDABLE TRANSPORTATION?   YES:   NO:

   IF YES: MAKE:   MODEL:   PAYMENT $:

   TOTAL HOUSEHOLD INCOME (MONTHLY) $:

          OTHER INCOME (AFDC, SSI, CHILD SUPPORT, AND ETC.) $:

HOUSING:

   DO YOU RENT: OR OWN:

   IF RENT, DO YOU WNAT TO OWN YOUR OWN HOME:

   MORTGAGE/MONTHLY PAYMENT $:
   UTILITIES: ELECTRIC, GAS, WATER, ETC. $:

   DO YOU RECEIVE SERVICES FROM THE DEPT. OF CHILDREN AND FAMILIES?
   YES:   NO:
   IF YES, PLEASE SPECIFY:
   IF NO, HAVE YOU APPLIED FOR SERVICES?  YES:   NO:
   WHEN:    WHERE:

LIST A RELATIVE NOT LIVING WITH YOU

   NAME:

   ADDRESS:
  PHONE:

MEDICAL

   WHEN DID YOU LAST SEE A DOCTOR?:
   REASON:

   HAVE YOU BEEN HIV TESTED?  YES:  NO:
   ARE YOU USING ANY PRESCRIPTION/NON-PRESCRIPTION DRUGS?  YES:   NO:
   IF YES, WHAT?:

   DO YOU DRINK ALCHOL?  YES:  NO:
   IF YES, WHAT AND HOW MUCH PER DAY?:

   DO YOU SMOKE?  YES:   NO:   IF YES, WHAT DO YOU SMOKE?:

SUPPORT GROUP

   DO YOU VOLUNTEER ANYWHERE?  YES:  NO:
   IF YES, ANSWER THE FOLLOWING QUESTIONS:
   ADDRESS:
PHONE:
   SUPERVISOR:

   DO YOU ATTEND ANY COMMUNITY/SOCIAL FUNCTION ON A REGULAR BASIS?
    YES:  NO:
    FAITH BASED:   AA:   N/A (Narcotics Anonumous):   COUNSELING:

I HEREBY GIVE PERMISSION FOR THE ABOVE INFORMATION TO BE VERIFIED BY H.E.L.P. OR ANY AGENCY/ORGANIZATION OR INDIVIDUAL DEEMED NECESSARY.

CLIENT'S SIGNATURE: ______________________________ DATE: ______________

INTAKE REPRESENTATIVE: __________________________ DATE: ______________