Intake Assessement Form Participant Info Full Name* Are you native to Wayne County? If no, Please provide native location Address City State Zip Code How many people are living at this residence with you? Are you a... Homeowner Renter If a renter, Who is your landlord? Phone Your primary contact number Email* Date of Birth Age Mailing List do you want to receive our newsletter and occasional announcements? How many kids?* Name and Ages of Kids* Schools Kids Attend?* Are you a grandparent raising grandchildren? Yes No Former Address Former City Former State Former Zip Are you a member of a local church? Highest Level of Education Are you currently enrolled in secondary education? Yes No Employer If not Employeed most recent employer? Why were you let go? Are you a Veteran? Are you on disability? If yes, Explain Additional Contact Person Relationship with Contact Person Initial Reason for Requesting Assistance? What is the main reason for coming in today? Photo ID* How did you hear about us?* Food/Clothing Do you currently receive Food Stamps? Yes No I have in the past but no longer do Food Needs: Health Have you been diagnosed with a mental illness? Are you receiving mental health service? Have you been diagnosed with any health conditions? If yes, please describe briefly? Substance Use History: Are you currently receiving medicaid or medicare? Yes No If yes, please provide any additional information will be helpful Addtional Health Information Rental and Utility Assistance Rent Assistance Description ( Dollar amount and details) Utility Assistance Description ( Dollar amount and details) Forget your private link? Click here to have it emailed to you.