House of Mercy Intake Form
Ministry Mission Statement: House of Mercy empowers those living with HIV or AIDS in their
transformation toward a more independent life.
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Date of Referral *
MM
/
DD
/
YYYY
Referring Person *
Referring Person Telephone number *
Referring Agency *
Application Date *
MM
/
DD
/
YYYY
Client ID  *
HIMS
Applicant Last Name *
Please provide your last name
First Name and Middle Initial *
Current Street Address *
Please provide full address, including city, state and zip code.
Zip Code of your last address *
Phone where applicant can be reached *
Please provide your current phone number.
Date of Birth *
Please provide your date of birth
MM
/
DD
/
YYYY
Place of Birth *
Please provide your place of birth
Gender *
a. Male
b. Female
c. Transgender
d. Non-binary
Click gender
Race *
a. White
b. Black/African American
c. Asian/Pacific Islander
d. Latinx/Hispanic
e. Native American
f. multi-racial
Click choice
if multi-racial please specify
Ethnicity *
a. Hipanic or Latinx
b. Non-Hispanic or Non-Latinx
Click ethnicity
What is the applicants primary language? *
Second language if applicable
What services are you seeking? *
Required
Please fax the essential documents listed below to (704) 825-9976

HOPWA Client Intake Form
Proof of residency (Valid NC/SC ID)
Proof of HIV Status
Proof of Income (2 months' worth if applicable)
Identification (Driver's license, State issue ID)
Proof of Health Insurance
Consent to Release Confidential information

I confirm that the information provide is true and accurate. I hereby give permission to contact any agency who could be helpful in understanding my situation, and I give consent to release information necessary to receive assistance from the House of Mercy. 


 *
Please type your full name in this field as your confirmation, permission and consent to release information.
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