Community Action of Greene County, Inc. Client Intake Form

TYPE OF INCOME

Enter below

INCOME *

PRIMARY

SECONDARY

PAYCHECK

PENSION

UNEMPLOYMENT

GENERAL ASSISTANCE

SSA

SSI /SSP

TANF

VETERAN BENEFITS

WORKERS COMPENSATION

ALIMONY

ANNUITY

TOTAL INCOME PRIMARY
TOTAL INCOME SECONDARY
SERVICES RECEIVED

Enter below

INCOME *

AMOUNT

WHO RECEIVES

CHILD SUPPPORT

INTEREST

SNAP BENEFITS

RENTAL ASSISTANCE

HEAP

MEDICAID

MEDICARE

WIC

CHILDCARE SUBSIDY

TOTAL AMOUNT OF SERVICES RECEIVED
TOTAL AMOUNT OF INCOME AND SERVICES RECEIVED

HOUSEHOLD MEMBERS
Name - APPLICANT information first *

Prefix First Name Last Name Suffix
Birth Date *

Month Day Year
Age *
Veteran *
Education Level *
Ethnicity *
Race *
Disabled *
Type of Health Insurance *
Enter Insurance
Housing *

Name - 2nd household member

Prefix First Name Last Name Suffix
Relationship
Please Enter
Birth Date

Month Day Year
Age
Veteran
Disabled
Ethnicity
Race
Education Level
Type of Health Insurance
Enter Insurance

Name - 3rd household member

Prefix First Name Last Name Suffix
Relationship
Please Enter
Birth Date

Month Day Year
Age
Veteran
Disabled
Ethnicity
Race
Education Level
Type of Health Insurance
Enter Insurance

Name - 4th household member

Prefix First Name Last Name Suffix
Relationship
Please Enter
Birth Date

Month Day Year
Age
Veteran
Disabled
Ethnicity
Race
Education Level
Type of Health Insurance
Enter Insurance

Name - 5th household member

Prefix First Name Last Name Suffix
Relationship
Please Enter
Birth Date

Month Day Year
Age
Veteran
Please Select
Disabled
Please Select
Ethnicity
Please Select
Race
Please Select
Education Level
Please Select
Type of Health Insurance
Enter Insurance

Name - 6th household member

Prefix First Name Last Name Suffix
Relationship
Please Enter
Birth Date

Month Day Year
Age
Veteran
Please Select
Disabled
Please Select
Ethnicity
Please Select
Race
Please Select
Education Level
Please Select
Disabled
Please Select
Type of Health Insurance
Enter Insurance
You have applied for one of the programs or services that are offered by Community Action of Greene County, Inc. As part of our commitment to the people in our communities, we want to supply you with all the available services that may pertain to your household. Based on the information you have given, you will be contacted by programs that may be of assistance to you or your family.

Florence Ohle, Executive Director

Name

First Name Last Name
Date
Briefly describe your situation and reason for visit:
Enter Here
Are you a Greene County Resident?

Yes No
How did you hear about us?
Enter Here
Does anyone in your household receive services such as public assistance, food stamps or HEAP?

Yes No
If yes, describe:
Enter Here
If yes, who is your case worker?
Enter Here
Have you received help from us for this issue in the past?

Yes No
If yes, descirbe:
Enter Here

CONFIDENTIAL INFORMATION RELEASE

TO BE COMPLETED IN OFFICE WITH STAFF
Date

Month Day Year
I, ____________________________________________ give permission to the staff of

Community Action of Greene County, Inc. to exchange information regarding my case

with any appropriate social service, child protective service, adult protective service,

medical, mental health or counseling agency, educational, housing, day care,

employment agency, employer or_________________________________________________________

___________________________________________________________.

Signature: ___________________________________________

Witness: ____________________________________________

CLIENT CODE OF CONDUCT

As a Client I will:

Treat everyone with respect and courtesy

Adhere to Community Action policies and guidelines

Work cooperatively with Community Action staff and volunteers

Commit no illegal or abusive act

Not engage in financial transactions with staff or volunteers

Smoke only in designated area and away from children

Report any unsafe conditions and accidents to staff as soon as possible

Sign and abide by the Confidentiality Statement

Refrain from the possession of all weapons

Community Action will:

Provide a safe environment

Refer clients to other professionals when appropriate

Provide training, case management, support and assistance

Treat everyone with respect and courtesy

Adhere to Community Action policies and guidelines

Work cooperatively with clients

Commit no illegal or abusive act

Not engage in financial transactions with clients

Smoke only in designated area and away from children

Sign and abide by the Confidentiality Statement

Refrain from the possession of all weapons

Client Signature__________________________________________________

Staff Signature___________________________________________________

Date_____________________________

EMERGENCY FOOD PANTRY GUIDELINES

An application must be completed, received and/or updated at every visit even if you have recently done so.

The food pantry will be available to eligible households (3) three times during a (6) six-month period. Referrals to other community food pantries may be made when appropriate or when one has exceeded their visits.

Food Pantry customers will be asked to sign off each time the pantry is utilized. This record will be kept on file by Community Action of Greene County, Inc. and will be available to the food pantry customer if they are unsure when they last used the pantry or if they have reached the (3) three times in (6) six-months guideline.

Community Action of Greene County, Inc. reserves the right to ask for household composition.

PLEASE SIGN ONCE PER VISIT ONLY

Date: ___________ Signature: __________________________

Date: ___________ Signature: __________________________

Date: ___________ Signature: __________________________

BUDGET WORKSHEET FOR ENTIRE HOUSEHOLD

FIXED EXPENSES

Amount

Rent/Mortgage

Car Insurance

Health Insurance

Car Payments

Loan Payments

Credit Card Payments

Child/Elder Care

Child Support Payments

Child's Allowance

Taxes

Alimony (Paid if any)

Other

VARIABLE EXPENSES

Amount

Groceries

Utilities

Transportation (gas, tolls, taxi)

Telephone

Cell Phone

Medical/Dental

Clothing

Cable, Satellite, Internet

Pet Care

Day Care

Personal Hygiene

Other

INCOME

Amount

JOB #1

JOB #2

JOB #3

GOVERNMENT SUPPORT

SPOUSE OR PARTNERS INCOME

CHILD SUPPORT - RECEIVED

INTEREST/DIVIDENDS/INVESTMENTS

OTHER

TOTAL INCOME
TOTAL EXPENSES
BALANCE (NEGATIVE) OR + POSITIVE

Should be Empty:

CLIENT INTAKE FORM

TYPE OF INCOME

SERVICES RECEIVED

HOUSEHOLD MEMBERS

CONFIDENTIAL INFORMATION RELEASE

BUDGET WORKSHEET FOR ENTIRE HOUSEHOLD