Intake Details - Use this form for utility assistance.

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Privacy Consent

“To determine whether you are eligible for rental assistance, I will need to ask you some questions about your household, income, and rental situation. The information requested and collected is for the purpose of processing your application to the Rental Assistance Program. All of the information collected is considered confidential and will not be discussed with anyone outside our agency, the United Way of Bruce Grey office without your permission. Do you consent to providing the requested information?"

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* 1. Privacy consent has been obtained

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* 2. First name of 211 staff completing form

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* 3. 211 call center doing intake

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* 4. Applicant's Name:

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* 5. Partner's Name (If applicable):

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* 6. Full Address (city, town, postal code, fire #):

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* 7. What is the best way to contact you (phone, email,)

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* 8. Phone # or email

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* 9. Number in Household:

 
Total #
Adults
Seniors
Children

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* 10. Type of household Income 

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* 11. Total household monthly income (everyone in the household)

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* 12. How much is the monthly rent?

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* 13. Any other needs that came up in conversation (if applicable):

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