Employer-Provided Health Insurance If Specify: _____________________________ Health Insurance obtained through COBRA Income received from any source? Yes No Client doesn’t know Client refused Income Type Monthly Amount Income Type Monthly Amount N Y $ VA Non-Service-Connected Disability N Y $ Unemployment Insurance Pension N Y $ Pension or Retirement income from a N Y $ Earned/Employed Income former job Supplemental Security Income (SSI) N Y $ Child Support N Y $ Social Security Disability Insurance (SSDI) N Y $ Alimony or other spousal support N Y $ VA Service-Connected Disability N Y $ N Y $ Worker’s Compensation Compensation Private Disability Insurance N Y $ Other Source, Specify: N Y $ N Y $ Retirement Income From Social Security General Assistance (GA) N Y $ Temporary Assistance for Families N Y $ (TANF) Client Income Total $ Prior Zip Code (Numbers Only): _______________________________ Veteran Information: DD214 Order Date: ___________/______________/______________ DD214 Receive Date: _________/______________/____________ Service Connected Disability: Yes No *Branch of military: Air Force Army Marines Navy Coast Guard Client Doesn’t Know Client Refused Other
Employer-Provided Health Insurance If Specify: _____________________________ Health Insurance obtained through COBRA Income received from any source? Yes No Client doesn’t know Client refused Income Type Monthly Amount Income Type Monthly Amount Unemployment Insurance N Y $ VA Non-Service-Connected Disability Pension N Y $ Earned/Employed Income N Y $ Pension or Retirement income from a former job N Y $ Supplemental Security Income (SSI) N Y $ Child Support N Y $ Social Security Disability Insurance (SSDI) N Y $ Alimony or other spousal support N Y $ VA Service-Connected Disability Compensation N Y $ Worker’s Compensation N Y $ Private Disability Insurance N Y $ Other Source, Specify: N Y $ Retirement Income From Social Security N Y $ General Assistance (GA) N Y $ Temporary Assistance for Families (TANF) N Y $ Client Income Total $ Prior Zip Code (Numbers Only): _______________________________ Veteran Information: DD214 Order Date: ___________/______________/______________ DD214 Receive Date: _________/______________/____________ Service Connected Disability: Yes No *Branch of military: Air Force Army Marines Navy Coast Guard Client Doesn’t Know Client Refused Other