Exit CCA Intake - English CCA Universal Intake Form - English Question Title * 1. Last name Question Title * 2. First name Question Title * 3. Current Address Question Title * 4. City/town Question Title * 5. Telephone Number Question Title * 6. Email Question Title * 7. Gender Female Male Other Question Title * 8. What is your race/ethnicity? Please check all that apply. White or Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Mixed race Question Title * 9. Date of birth Question Title * 10. Are you a veteran? Yes No Question Title * 11. Are you disabled? Yes No Question Title * 12. Do you have health insurance/health coverage? Yes No Question Title * 13. What type of health insurance /health coverage do you have? HUSKY Employer insurance plan Medicare Medicaid Access Health Other Question Title * 14. What is your monthly household income? no income less than $500 $500 - $999 $1,000 - $1,499 $1,500 - $1,999 more than $2,000 Question Title * 15. What is the source of your household income? Please check all that apply Alimony/spousal support Child support Earned income (employment) Child tax credit General Assistance (GA) Pension/retirement from job Retirement income from social security Private disability insurance Social Security Disability Insurace (SSDI) Supplemental Security Income (SSI) TANF Unemployment Insurance VA non-service connected disability pension VA service connected disability pension Workers compensation Other Question Title * 16. How many adults are in your household? Question Title * 17. How many children under the age of 18 are in your household? Question Title * 18. Are you interested in life skills training? Yes No Question Title * 19. How comfortable are you with finding/getting help through the social services system? For example, DSS, DCF, TANF, SNAP, Social Security Office, Medicaid/HUSKY, food pantries, clothing closets, health clinics, energy assistance. Not comfortable Somewhat Comfortable Very Comfortable Question Title * 20. What program are you being enrolled in today? Hillside Family Shelter New HOPE Housing Assistance with housing needs (other than shelter) Diaper bank Energy assistance (heating source) Operation Fuel (utility assistance) Food pantry Security deposit Rental assistance Employment assistance Childcare assistance Advocacy Professional clothing closet Assistance with obtaining physical health care Assistance with obtaining mental health care Other (please specify) Question Title * 21. Is there anything else that CCA can assist you with? Please check all that you would like more information about. Assistance with housing needs Diaper bank Utility assistance Food pantry Security deposit Rental assistance Employment assistance Childcare assistance Advocacy Professional clothing closet Assistance with obtaining physical health care Assistance with obtaining mental health care Other (please specify) Question Title * 22. This section to be answered by CCA staff Client referred to another CCA program Question Title * 23. CCA staff notes Done
