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Info: Tell us about your need: INTAKE FORM
Posted on Wednesday, November 25 @ 08:51:33 PST by John
Every step of help we provide starts with learning more details. This means that you fill out the Intake Form below and email it to us at Love.INC.SC@Gmail.com Click on "Read More" ...
Drag and Copy everything below this point. Then open your email and Paste it in a new letter to us. Switch on your CAPS LOCK and fill in the answers and then Send it to us. If you have email using that is best but here is the regular mail info: PO Box 1602, Soquel, CA, 95073
Love in the Name of Christ Intake Form
Greetings,
We need you to complete this to determine what kind of help is best for you.
Do we have your permission to verify the information you give to us? Yes No
If Love INC is not able to verify information we will be unable to help you.
[However, we can refer you for clothing and or food.]
Do you understand that we are a Christian clearinghouse? That means that we have limited funds here, we are not a Crisis Center but we will network you to help that has been offered. We will take your application and try to match your needs with resources that may be available to help you; or we will refer you to programs that may help. We strongly encourage you to follow thru with any referrals we give you. It will take 3 to 7 working days to process your application and we will try to get back to you in that time.
___________________________________________________________________
QUESTIONS:
Name:
Address:
Phone numbers:
Email:
Marital Status:
single, married, live-in, divorced, separated, widowed
Spouses name: DOB: / /
Last four digits of YOUR SS# -
Do they pay child support?
If no, why not?
Number of children living with you: Ages: .
Total number in household:
What is your chief need at this time?
What has changed since last month that has caused you to be unable to meet this need yourself?
How will you be able to meet this need next month?
WORK HISTORY
Are you employed?
Current employer name:
Phone #
How long?
Position:
Hours per week:
Wage:
Last check date:
Amount:
.
If not working reason:
Would you like to receive job training:
How long have you been off work?
Name of last employer:
Phone#
Is mate/other employed? Yes No
Employer name:
Phone
How long?
Position:
Wage:
If not working reason:
LANDLORD
Do you Rent or Own or have HUD housing?
Utilities included: Yes or No
How much can you pay toward this amount due?
Is there an eviction notice?
Landlord’s Name:
Phone #
Address:
<>< <>< <>< <>< <>< <>< <>< <>< <>< <>< <>< <><
(This is essential if the need is for rent or mortgage)
***verify Landlord information: Name of person talked to?
EXPENSES (Approximate amount of $ spent monthly on)
Rent/house payment:
Food: $
Car payment $
Credit Cards $
Home Owners lns $
Car lns $
Medical Bills $
Other $
Gas $
Cable TV$
STORAGE
Phone $
PG&E $
Cell Ph $
WATER $
INCOME SOURCES
Source ... Amount ... Date of last Check ... Date filed
SSI $
Food Stamps $
AFDC $
WIC $
Child Support $
Unemployment$
Workers comp $
Social security $
Disability $
Veterans Benefits$
Widows Benefits $
Pension $
OTHER $
Total amount of EXPENSES $
Total amount of INCOME $_________
Difference?
1. Do you have family in or out of town?
List them:
2. Would you consider financial counseling?
We can have a church member come out and help you.
3. Would you like a “Neighborly Visit” from someone in your area?
Yes No
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