ARHA's Referral Intake Application

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100% of survey complete.

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* 1. Today's Date:

Today's Date

Date

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* 2. Share with us who you are

Full Name

Address

City, State & Zip

Email Address

Phone #

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* 3. Who is your case-manager?

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* 4. Are you the head of household?

Yes

If No, Who Is?

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* 5. How many children under the age of 18 live in your household?

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* 6. What is your monthly rent payment?

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* 7. What is your monthly income?

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* 8. What is the monthly income of persons in your household 18 and over?

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* 9. What benefits are you currently receiving?

Public Housing

Housing Choice Voucher (Section 8)

TANF

Medicaid

SNAP (Food-Stamps)

Childcare

Social Security/SSI/SSD/SSA

Veterans Disability

Unemployment

Utility Allowance

I Don't Receive Any Assistance

Other (specify)

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* 10. Do you receive a utility allowance?

Yes

If yes, how much?

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* 11. What is your Date of Birth?

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* 12. What is the highest level of school you have completed or the highest degree you have received?

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate degree

Bachelor degree

Graduate degree

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* 13. Which of the following categories best describes your employment status?

Employed, working 40 or more hours per week

Employed, working 1-39 hours per week

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

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* 14. Are you currently enrolled as a student?

Yes, full time

Yes, part time

No, I am not currently enrolled as a student

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* 15. Are you currently enrolled in the Family Self-Sufficiency Program?

Yes

On Waiting List

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* 16. What is your reason for needing Referral Services?

Rent

Eviction Notice (2130)

Utility Disconnection Notice

Sewage Disconnection

Water Disconnect Notice

Security Deposit

Maintenance

Other (please specify)

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* 17. Have your received referral support services in the past?

Yes

If Yes, when was the last time and what was the assistance

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* 1. Today's Date:

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* 2. Share with us who you are

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* 3. Who is your case-manager?

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* 4. Are you the head of household?

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* 5. How many children under the age of 18 live in your household?

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* 6. What is your monthly rent payment?

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* 7. What is your monthly income?

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* 8. What is the monthly income of persons in your household 18 and over?

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* 9. What benefits are you currently receiving?

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* 10. Do you receive a utility allowance?

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* 11. What is your Date of Birth?

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* 12. What is the highest level of school you have completed or the highest degree you have received?

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* 13. Which of the following categories best describes your employment status?

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* 14. Are you currently enrolled as a student?

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* 15. Are you currently enrolled in the Family Self-Sufficiency Program?

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* 16. What is your reason for needing Referral Services?

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* 17. Have your received referral support services in the past?

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* 18. Reason for assistance or request? PLEASE GIVE DETAILS!