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Helping Families Intake Form
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2022-09-07T17:56:08+00:00
Referred By:
*
First Name
*
Last Name
*
Date of Birth
*
Today's Date
*
Address
*
City
*
State
Zip
*
Email
*
Best Contact Number
*
Do you have a child currently attending a school in Lexington School District Two?
*
Yes
No
If yes, which school?
Are you currently employed?
*
Yes
No
What is the name of your employer?
In what county do you reside?
*
What is your household size?
*
What is your monthly household income?
*
What is the source of your household income?
*
What assistance are you seeking?
*
Select All That Apply
Food
Clothing
Temporary shelter
Finding a job
Adult education
Obtain housing
Creating a monthly budget
Utility assistance
Legal services for dispute with landlord
Assistance with scheduling medical appointment for a child
Mentor/tutoring/homework assistance for a child
Counselor/Social Worker Comments
Submit
Thank you for submitting your intake form for assistance and support. The Brookland-Lakeview Empowerment Center and the Siemer Institute: Two-Generation Approach Social Worker, Mrs. Theresa Hill, will contact you very shortly.
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