Client Intake Form | Restoring Love

Prints on US Letter, 2 pages

Restoring Love Church

80 Shepard St, Battle Creek, MI

(269) 716-5937

Client Intake Form

Today's date:

Intake date:

Name:

DOB:

Phone:

Email:

Photo

Items	Status	Notes	Appointments
Registered	In progress Done
Caseworker	In progress Done
Neighborhoods Inc.	In progress Done
Photo ID or driver's license	In progress Done
Social Security card	In progress Done
Birth certificate	In progress Done
Phone number	In progress Done
Email address	In progress Done
Bridge card / EBT	In progress Done
Medicaid	In progress Done
Summit Pointe	In progress Done
Counselor	In progress Done

Where to find them

Staying atMailingOther

Has transportation? YesNoLives in a car? YesNo

Notes:

Who	Name	Phone	Notes
Caseworker, doctor, counselor
Caseworker, doctor, counselor
Caseworker, doctor, counselor
Caseworker, doctor, counselor

Benefit	Status	Notes
SSI	NeedsAppliedHas itNot eligible
SSDI	NeedsAppliedHas itNot eligible
Medicaid	NeedsAppliedHas itNot eligible
Medicare	NeedsAppliedHas itNot eligible
Bridge card / EBT	NeedsAppliedHas itNot eligible
Other	NeedsAppliedHas itNot eligible

Shelter history (include if kicked out)

Housing history (include evictions)

Housing voucher: No voucherAppliedOn waitlistApproved

Voucher notes:

Sober since:

Sober living places:

Notes:

Program	Status	Dates	Notes
Substance abuse and inner healing curriculum(required)	Not startedEnrolledCompleted
Hope University(optional)	Not startedEnrolledCompleted

Working? YesNo

Where:

Notes: