Central Ohio Pathways HUB Rental/Utility Assistance Referral Form

Client Information:

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* 1. Head of Household Name, First & Last:

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* 2. Head of Household Date of Birth

Date / Time

Date

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* 3. Head of Household Preferred Gender Identity:

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* 4. Head of Household Race/Ethnicity:

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* 5. I am applying for:

Rental Assistance

Utility Assistance

Both Rental and Utility Assistance

If neither utility or rental assistance is needed, but you'd like to receive HUB services, please click here

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* 6. Head of Household lives at the following CMHA Property or has a housing voucher at:

Other (please specify)

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* 7. Head of Household Street Address

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* 8. Head of Household City, State, Zip Code:

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* 9. Head of Household Best Contact Phone Number:

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* 10. Head of Household Best Contact Email:

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* 11. Preferred form of contact:

Phone

Both Phone and Email

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* 12. Referring Agency (if not client self referral) Best Contact (Phone Number/Email):

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* 13. Other than needing rental/utility assistance, please check all areas of concern :

Alcohol/Substance Abuse

Asthma

Childcare

Clothing

COVID-19

Depression or Other Mental Heath Concern

Developmental Delay of Child in Family

Domestic Violence

Education Assistance

Family History of Child Abuse/Neglect or Involvement with CPS

Family History of Heart Disease/ Diabetes

Financial (including utility) Assistance

Food

Housing

Insurance

Job/Employment

Legal

Low Income

Medication Assistance

Obese

Physically inactive

Poor Diet

Smoker/Tobacco User

Stress

Transportation

Child under age of 18 living in the home

Pregnant

Other :

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* 14. If pregnant please indicate estimated delivery date:

Date / Time

Date

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* 15. Insurance Status:

Medicaid

Medicare

Uninsured

Private

Unknown

Medicaid Managed Care Plan Name

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* 16. Please provide any additional information that may be helpful to the Pathways HUB:

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* 17. By checking this box, I attest to being head of household and give consent, with full understanding that I am sharing the above information with the Central Ohio Pathways HUB and the Columbus Metropolitan Housing Authority for the purposes of being connected to rental and/or utility assistance, and potentially other services I and the Community Health Worker deem necessary via enrollment into the Pathways Program.

I give consent

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* 18. Client Consent

Print Name:

Date (MM/DD/2020):