Who referred you? Check / Circle one: Security Administration or Disability Determination Services Social Hospital, Mental Health Doctor, enforcement, Corrections, Connect, Workers’ Comp. Law Job program in your community or public assistance agency Rehabilitation Welfare College, or Vocational school school or high school University, Grade Friend, Family Self-referral, Administration Veteran’s Other Please check one of the following which best describes your current living arrangement: residence (On your own, with family or roommate) home Private Group facility health facility home Rehabilitation Mental Nursing correctional facility house Jail/Adult Halfway Homeless/shelter abuse treatment center Substance Other MARITAL STATUS Would you like to register to vote today SINGLE MARRIED Form# Yes No SEPARATED Please select one: DIVORCED WIDOWED registered Eligible Interested Currently Not Not House hold Information: Number in Family Number of Dependents Parents monthly income if under age 18 House hold members: Name: Age:_ Relationship: Occupation: Name: Age:_ Relationship: Occupation: Name: Age:_ Relationship: Occupation: What is your primary (largest) source of support? Monthly Amount $ Check one of the following: personal income (earnings, interest, dividends, rent) Your spouse’s income, or support from family and friends Your support such as SSDI, SSI, TANF, etc. Public sources such as insurance or charities Other RECEIVED BY: Agency Representative :
Who referred you? Check / Circle one: Social Security Administration or Disability Determination Services Doctor, Hospital, Mental Health Law enforcement, Corrections, Job Connect, Workers’ Comp. Rehabilitation program in your community Welfare or public assistance agency University, College, or Vocational school Grade school or high school Self-referral, Friend, Family Veteran’s Administration Other Please check one of the following which best describes your current living arrangement: Private residence (On your own, with family or roommate) Group home Rehabilitation facility Mental health facility Nursing home Jail/Adult correctional facility Halfway house Homeless/shelter Substance abuse treatment center Other Would you like to register to vote today Yes No Form# Please select one: Currently registered Not Eligible Not Interested MARITAL STATUS SINGLE MARRIED SEPARATED DIVORCED WIDOWED House hold Information: Number in Family Number of Dependents Parents monthly income if under age 18 House hold members: Name: Age:_ Relationship: Occupation: Name: Age:_ Relationship: Occupation: Name: Age:_ Relationship: Occupation: What is your primary (largest) source of support? Monthly Amount $ Check one of the following: Your personal income (earnings, interest, dividends, rent) Your spouse’s income, or support from family and friends Public support such as SSDI, SSI, TANF, etc. Other sources such as insurance or charities RECEIVED BY: Agency Representative :