Intake Form
Please email ID, and proof of income when submitting this form to Info@hhrcenter.org In your email please let us know that you have submitted your intake form.

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Email *
Applicant  Information
First and Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Home/ Cell Phone Number *
Current Address *
Zip Code *
City *
State *
Race
Marital Status *
How did you hear about us? *
Required
Housing and Income info
Please fill out to the best of your ability
Housing Status *
Housing Type *
$                           Rent/House payment? *
Income *
Required
Education *
Medical History
Employment
Current Employer
How long? *
Emergency contact *
Personal History
Have you experienced abuse? *
What services are you interested in receiving?  (Check off as many as apply)
Self
Family member
Yes
Advocacy
Donation closet
Go Bag with toiletries
Trauma Education
Learning about essential oils
Healing art
Do you have any history of substance abuse?
Clear selection
Have you been convicted of a crime? *
Do you have an open case with Children's protective services? *
Family Members living with you
Name
Date of birth
MM
/
DD
/
YYYY
Gender
Relation
Name
Date of birth
MM
/
DD
/
YYYY
Gender
Clear selection
Relation
What are your current needs? *
Application Certification
The information provided by me to establish my eligibility is true and accurate to the best of my knowledge and it is not provided with the intent to
defraud. I hereby acknowledge that the information relating to determine my eligibility requires verification and/or documentation and by my signature,
I authorize others to release such information as may be required for the determination of my eligibility. Furthermore, I authorize Helping Hands to
share personal information concerning my transactions with other emergency service providers for the purpose of official business only. I understand
that in all other respects the confidentiality of my personal information will be safeguarded. I understand that Helping Hands has the right to refuse
service to me and my family.
Do you agree with the Application Certification *
Required
Type your name after you agree *
Date *
MM
/
DD
/
YYYY
Advocate that received Intake Form(office use only)
Please check one off
Karen Gonzalez-Torres
Karen Revelo
Andres Torres
Michelle Solares
Kimberly Gomez
Clear selection
Date advocate received Intake
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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