Is there a release of Yes information to contact this person? Continue to Household Income Household Income Does the household have any current income? Yes No Client Does Not Know Client Refused     answer the following question and move on to Household Income for AMI Below: If No, Do you need assistance in applying for cash benefits?  Yes  No If Yes: Please indicate in each source if the household receives the income, and if they do, the household member receiving the income, the monthly amount (to the nearest dollar) of each source, and the income start date. HH Member Amount Start Date HH Member Amount Start Date Earned Income $ $  If Yes: Yes No $ $ Unemployment Insurance  If Yes: $ $ Yes No SSI: Supplemental Security Income  If Yes: $ $ Yes No SSDI: Social Security Disability Income  Yes No If Yes: $ $ VA Service Connected Disability Compensation  If Yes: $ $ Yes No Private Disability Insurance  If Yes: $ $ Yes No Compensation Worker’s If Yes: $ $  Yes No TANF: Temporary Assistance for Needy Families  If Yes: $ $ Yes No General Assistance  If Yes: $ $ Yes No Retirement Income from Social Security  If Yes: $ $ Yes No VA Non-Service Connected Disability Pension  If Yes: $ $ Yes No Pension or retirement income from another job  Yes No If Yes: $ $ Child Support  If Yes: $ $ Yes No Alimony or Other Spousal Support  If Yes: $ $ Yes No Other Source (specify):  If Yes: $ $ Yes No
Is there a release of information to contact this person? Yes Continue to Household Income Household Income Does the household have any current income?  Yes  No  Client Does Not Know  Client Refused If No, answer the following question and move on to Household Income for AMI Below: Do you need assistance in applying for cash benefits?  Yes  No If Yes: Please indicate in each source if the household receives the income, and if they do, the household member receiving the income, the monthly amount (to the nearest dollar) of each source, and the income start date. HH Member Amount Start Date HH Member Amount Start Date Earned Income  Yes No If Yes: $ $ $ $ Unemployment Insurance  Yes No If Yes: $ $ SSI: Supplemental Security Income  Yes No If Yes: $ $ SSDI: Social Security Disability Income  Yes No If Yes: $ $ VA Service Connected Disability Compensation  Yes No If Yes: $ $ Private Disability Insurance  Yes No If Yes: $ $ Worker’s Compensation  Yes No If Yes: $ $ TANF: Temporary Assistance for Needy Families  Yes No If Yes: $ $ General Assistance  Yes No If Yes: $ $ Retirement Income from Social Security  Yes No If Yes: $ $ VA Non-Service Connected Disability Pension  Yes No If Yes: $ $ Pension or retirement income from another job  Yes No If Yes: $ $ Child Support  Yes No If Yes: $ $ Alimony or Other Spousal Support  Yes No If Yes: $ $ Other Source (specify):  Yes No If Yes: $ $
SubCook_Initial_Intake_Assessment_20181001.docx