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CRISIS INTERVENTION INTAKE <br />NAME <br />DATE / / <br />SS# - - <br />Last First <br />ADDRESS: <br />ZIP <br />NO <br />PHONE <br />REQUEST: FOOD RENT UTILITY CLOTHING TRANSPORT ID OTHER <br />COMPLETE THIS SECTION FOF <br />How long have you lived in this area? <br />Reason for coming to this area? <br />Name of family/friend in the area? <br />Work Experience? <br />Relationship? <br />Degrees/Cert? <br />GENDER: MALE FEMALE ID ID TYPE(#) <br />ETHNICITY: African-American Asian-American Caucasian Hispanic Native American Other_ <br />u.,..?eh.,1.J !`n.,,nn?itinn• Mirnhnr in hnucahnlrl' Number of Children <br />FIRST NAME MI LAST NAME DOB SEX RELATION <br />Sources of All Household Income: <br />EMPLOYER (S) TYPE OF WORK: <br /> <br />JOB: Hours/Wk /Wk UNEMPLOYMENT $ /Mo. SOC SEC $ /Mo. <br />Pay rate /Hr CHILD SUPPORT $ /Mo. DISABILITY $ /Mo. <br />Take Home /Mo. WORK FIRST $ /Mo. SSI $ /Mo. <br /> FOOD STAMPS $ /Mo. WIC (Y/N) $ /Mo. <br />CLIENT RELEASE OF INFORMATION: <br />I hereby give the Inter-Faith Council permission to contact, discuss, or otherwise secure information from any person, <br />agency, or business necessary for the purpose of reviewing my case. Any information or records so obtained may be used <br />or communicated by the Inter-Faith Council to any person, agency, or business for any reasonable purpose. <br />Client/Representative Signature <br />A <br />Attachments II & III <br />APPT. TIME <br />DOB I I <br />- Chapel Hill Carrboro Other <br />HAVE YOU BEEN HERE BEFORE? YES or <br />From? <br />How long there? <br />MI <br />Years Education?