Client Survey

Client Survey
Name

First Name Middle Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth

Month Day Year
Date
Last four numbers of your Social Security Number
Email
example@example.com
Phone Text

Area Code Phone Number
Phone VP

Area Code Phone Number
Hearing Status
Do You Need Hand Sanitizer and Masks?

hand sanitizer masks both
What is Your Primary Language?
Are you in a high-risk group for COVID-19? If yes, please explain.
Have you had COVID-19? If yes, please explain.
Have you been exposed to COVID-19 and been required to quarantine? If yes, please explain.
Do you have school-age children in virtual school as a result of COVID-19? If yes,please explain.

Housing
Do you have a place to live now?
If yes, where?
How many people live in your home? Please list all names and their relationship to you (friend, spouse, son, daughter, sister, brother, etc.)
Do you rent or own?

rent own
Monthly amount of mortgage or rent.
Have you missed any rent or mortgage payments due to COVID-19? If yes, how many months do you owe?

yes no
Have you been evicted because of COVID-19?

yes no
Contact information for Bank or Landlord.
If we have your permission to communicate with your Bank or Landlord, sign and date here.

Clear
Have you missed any utility payments for water, electricity, or natural gas due to COVID-19? If yes, plesae include the name of the utility company and the amount that is past due.

yes no
Expenses have increased due to COVID-19 $ blanks
Expenses have remained the same since COVID-19 $ blanks
Expenses have decreased since COVID-19 $blanks

Technology
Do you have internet access?

yes no
If yes, how? Phone only or do you have internet at home?
If you have internet at home, who is your provider?
Do you have a laptop or tablet?
Would a laptop and internet help you with education, jobs, training, information, news? Please explain.
Would a laptop and internet help keep you safer during COVID-19? Please explain.
Do you need training on how to use a computer?

yes no
Do you have a VP in your home?

yes no
Why or why not?
Do you have other assistive technology in your home (flashing doorbell, flashing fire alarm, bed shaker, caption phone, etc.?) Please list.

I attest that, to the best of my knowledge and belief, all information submitted here is accurate and true. The needs I have included are due to COVID-19. I understand that, if the information is determined to be false, I will be responsible for returning any funds received. *
Signature

Clear
Date Client Contacted

Month Day Year
Date
Notes
Date of Contact with Resources (Landlord, Utilities, etc.)

Month Day Year
Date
Approved or Declined
Date Approved or Declined

Month Day Year
Date
Should be Empty:

Employment