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WFAP client information for service request
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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WFAP NEW CLIENT INFORMATION FOR SERVICE REQUEST
1
Full name:
2
Address (City, State, Zip):
3
Phone number:
4
Email:
5
Emergency contact phone number:
6
Emergency contact name:
7
Relationship with emergency contact:
8
Date of birth: (MM/DD/YYYY)
9
Employed?
Select one answer
Yes
No
10
If employed who is your employer?
11
Hourly pay:
12
How often paid:
13
How long employed:
14
Do you belong to a local church? if so, where do you attend?
15
Are you receiving any other assistance? (SNAP, Medicaid, TANF, SSI, etc.):
16
Are you receiving/paying child support? Please explain the current status:
17
Please list names, relationship, and ages of all household members:
18
Do you have permanent housing?
Select one answer
Yes
No
19
What actions have you taken?
20
What do you hope to gain from this experience?
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WFAP NEW CLIENT INFORMATION FOR SERVICE REQUEST
21
Are you currently involved in a domestic situation or are you in fear of your/your children(s) lives? if yes, please explain in detail below:
22
Are your expenses paid up to date?
Select one or more answers in each row
Yes
No
N/A
Rent/Mortgage:
Gas:
Electric:
Childcare:
Insurance:
other:
23
Clothing needs:
Select one or more answers in each row
Yes
No
Shirts:
Pants:
Undergarments:
Socks:
Shoes:
24
Other clothing needs that are not listed:
25
Please leave a detailed description on all sizes needed:
26
How will receiving our assistance change your life going forward?
27
How will this assistance make you feel?
28
Would you recommend this program to other single parents? Why or why not?
29
Please list other needs below:
30
Do you have any medical issues or concerns we should take into consideration? (If so, can you provide documentation for this?)
Select one answer
Yes
No
31
Please understand out of respect, safety, and privacy, we keep all of our client's information confidential. We do not release any personal documentation to anyone without permission from our client. However, under reasons of self-harm, harm to others, unlawful or signs of behavior that would be considered abuse, illegal, or unsafe. Such agreement will be waived & we are mandated to report such information to agencies applicable. Do you understand and accept these terms?
Select one answer
Yes
No
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