Assistance-Application

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Love INC of Cowlitz County Assistance Application

TYPE OF ASSISTANCE NEEDED:

Need Food Financial

Have You worked with Love INC before?

Yes No

Today's Date:

How long have you been a resident of Cowlitz County?

First Name:

Middle Initial

Last Name:

Date of Birth

Best Contact Phone:

Alternate Contact Number:

Email Address:

Physical Address:

City, State, Zip:

If no permanent address, where are they currently living?

City, State, Zip:

Relationship Status

Single Married Divorced Widow Widower Other Prefer not to say

When we reach out, is it ok to leave a message?

Yes No

Does the state of Washington Consider you to be? [check all that apply]

Low Income Disabled Veteran SIngle Parent Elderly

Referral Information

Who Referred You?

Relationship

Phone #:

Churches Name:

Name of Individual at the church

Phone #:

Agency's Name

Caseworker Name

Phone #:

Part of our process is to talk with those who are familiar with your situation and can help us understand your needs better, such as family, case managers, church, landlord, or employer, depending upon the request.

Do we have your permission to carify the information you have given to us with the references you provide?

Yes No

Is anyone in the home a Veteran?

Yes No

Optional: If yes, Name of Veteran

Are there any other adults or children in the home?

Yes No

Total Living in Household

Spouse/Partners Name?

Date of Birth

Other Adults in home

Gender?

Male Female

Age

Date of Birth

Relationship

Other Adults in home

Gender?

Male Female

Age

Date of Birth

Relationship

Are you Connected to any other support systems? i.e counseling, groups, classses?

Yes No

If yes, Name?

Do you attend a local church?

Yes No

If yes, Name?

Pastors Name

Contact Number

If No, Can we help you get connected with a church?

Yes No

Which of the following Classes would you find helpful as we hold them or find a resource in the community who does?

Finances Marriage Parenting Cooking Job Preparation Bible Study

Do you have any questions of us that we can have answers for when we contact you?

A member of Love INC will be reaching out to you to do additional follow up on your situation personally. Please be expecting us to reach out.

I want to assure you that the information in this interview is confidential and will not be shared outside of the Love INC staff. The information will be used to help create a plan of action to begin working on goals and objectsyour current situation.

Thank you for taking the time to reach out and fill this form out.

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Love INC of Cowlitz County Assistance Application

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