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

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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:

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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:

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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 :

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* 14. If pregnant please indicate estimated delivery date:

Date

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* 15. Insurance Status:

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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. 

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* 18. Client Consent

T