New Client Intake Form

Please set aside 30-45 minutes to complete this form.

**You may save the form and return later by using the Save + Continue button at the bottom of the form

You’ll receive a unique link which will be displayed on the page. The link is similar to a password so it’s strongly advisable to ensure that you store it securely. If you lose this link, you will not be able to recover your saved form.**

Have you received services form Love INC in the past 3 years?(Required)

Personal Information

Full Name(Required)

First Middle Last

Street Address(Required)

Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address (If different from home)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Personal Phone(Required)

Message Phone (If different)

Name of Person at Message Phone

First Last

Your Email(Required)

Date of Birth(Required)

Age(Required)

Household Information

Marital Status

Partner's Name

First Last

Partner's Date of Birth

Do you have children in the home?

Children's Information(Required)

First Name

Last Name

Date of Birth

Relationship

School

Father's Name

Press the (+) button to add a new line for each child

Are there others in the your home besides you, your partner, and/or children listed above?

Total in Family(Required)

Please enter a number from 1 to 12.

Total in Household(Required)

Please enter a number from 1 to 12.

Will your household size change in the next 3 months?(Required)

How long have you lived at your residence?(Required)

Have you been a resident of Madera 6 months or longer?

What is your housing situation?

Rental Information

Landlord's Name(Required)

Landlord's Phone(Required)

Date Rent is Due(Required)

Are you current on your rent?(Required)

Amount owed for eviction (if any)

Does an agency assist you with your rent?(Required)

Name of Agency(Required)

What portion of the rent do they pay? (Dollar amount)(Required)

How much is your full rent?(Required)

What portion do you pay?(Required)

How long do you plan to stay?

Please describe your housing situtation(Required)

Household Members' Income

Sources of Income/Assistance [Please include each source of income/assistance on a new line by clicking the (+) button.]

Possible sources of income to include: Food Stamps, Cash Aid, Disability, Vets Disability, Other Grants, Medi-Cal/Medicare, WIC, Self-Employment, Wages (Net), Unemployment, Social Security (Retirement), Retirement/Pension, Veteran's Retirement, Child Support/Alimoney, and Other any other sources

Your Amount

Your Partner's Amount

Other Amount

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Sources of Income/Assistance [Please include each source of income/assistance on a new line by clicking the (+) button.]

Your Amount

Your Partner's Amount

Other Amount

Household Members' Expenses

Rent/Mortgage

Your Amount

Your Partner's Amount

Other Amount

Electricity/Gas

Your Amount

Your Partner's Amount

Other Amount

Other Utilities (water, sewer, garbage)

Your Amount

Your Partner's Amount

Other Amount

Phone

Your Amount

Your Partner's Amount

Other Amount

Internet/Cable

Your Amount

Your Partner's Amount

Other Amount

Groceries/Food

Your Amount

Your Partner's Amount

Other Amount

Car Payment

Your Amount

Your Partner's Amount

Other Amount

Car Insurance

Your Amount

Your Partner's Amount

Other Amount

Credit Card/Loans

Your Amount

Your Partner's Amount

Other Amount

Eating Out/Movies

Your Amount

Your Partner's Amount

Other Amount

Toiletries (hygiene, etc.)

Your Amount

Your Partner's Amount

Other Amount

Haircuts, beauty, nails

Your Amount

Your Partner's Amount

Other Amount

Gas, Bus, Transportation

Your Amount

Your Partner's Amount

Other Amount

Health Insurance

Your Amount

Your Partner's Amount

Other Amount

Medical Bills, Prescriptions

Your Amount

Your Partner's Amount

Other Amount

Clothing, Shoes, Etc.

Your Amount

Your Partner's Amount

Other Amount

Payday, Rent to Own Loans

Your Amount

Your Partner's Amount

Other Amount

Education (books, supplies)

Your Amount

Your Partner's Amount

Other Amount

Child support/alimony

Your Amount

Your Partner's Amount

Other Amount

Other (cigarettes, alcohol)

Your Amount

Your Partner's Amount

Other Amount

Verifying documents

In order to verify the information you provide, we need proof of income and proof of identification. Verifications of income include copies of all forms of income in the household.

Please upload verification documents here(Required)

Drop files here or

Accepted file types: pdf, doc, jpg, png, jpeg, Max. file size: 128 MB, Max. files: 6.

Assistance Needed

Please let us know your most pressing need:(Required)

Who referred you? Please be specific (first and last name)(Required)

Phone of person who referred you(Required)

Do they receive services through Love INC?(Required)

Have you applied for assistance elsewhere?(Required)

Have you contacted friends/family for assistance?(Required)

Do you have a caseworker?(Required)

Please share a little bit about the circumstances that led you to have this need:(Required)

Love INC provides classes in budgeting, nutrition and exercise, soft vocational skills, and healthy relationship. Would you like to know more about these opportunities?(Required)

Signature(Required)