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Intake Form – for Data Entry

Client Intake Form (#22)

OFFICE USE ONLY

Is this client already in the database?

Yes

No

Original Submission ID

Request Date

Request Type

Direct

Event

Client Certification

New

Recertification

Date Last Served

How Served?

Direct

Event

DISTRIBUTION SCHEDULING

Generic Distrib Code

Distrib Start Date

Distrib Interval

Scheduled Distrib Code

Scheduled Product Code 1

Scheduled Product Code 2

DISTRIBUTION COMPLETION

First Service Contact Date

Final Service Date

Received Product Code 1

Received Product Code 2

Funding Source

Service Status

Picked Up

Delivered

Restock

Closed-no fill

Closed-no reply

Closed-duplicate

Processed By

Entered By

CLIENT DOCUMENTATION

Are you completing this form at a Giving to the Nations OUTDOOR event?

Yes

No

How did you hear about Giving to the Nations?

Please answer the 5 questions below.

How did you learn about our program?

More information about the person or organization that referred you.

What is the title or position of the person who referred you?

What is the person's name who referred you?

Please tell us anything else you would like us to know about how you heard about Giving to the Nations or our program.

Have you used our services before?

Yes

No

Are you currently homeless?

Yes

No

CLIENT INFORMATION

First Name

Last Name

Address

Address 1

Address 2

City

State

Zip Code

County

Address type?

Mailing address only

I live at this address

Phone

Type

Mobile

Other

Email

Best contact method (What is the best way to get ahold of you?)

Phone Call

Email

Text

Would you like to be notified of upcoming events? (By email ONLY)

Yes

No

Household Information

List everyone that lives in your home.

Males Under 5 Years

Females Under 5 Years

Males 5-9 Years

Females 5-9 Years

Males 10-14 Years

Females 10-14 Years

Males 15-17 Years

Females 15-17 Years

Males 18-24 Years

Females 18-24 Years

Males 25-34 Years

Females 25-34 Years

Males 35-44 Years

Females 35-44 Years

Males 45-54 Years

Females 45-54 Years

Males 55-64 Years

Females 55-64 Years

Males 65-84 Years

Females 65-84 Years

Males 85 Years and Over

Females 85 Years and Over

Tell us more about any children under 5 years old.

Any children in your home Newborn to 2 years old?

Yes

No

MILITARY STATUS

Please choose one

Military Status

Active Duty

Retired

Reserves/Nat'l Guard

Veteran

Did Not Serve

PLEASE SELECT YOUR RACIAL CATEGORY

Please choose one

Racial Category

White

Asian

Black or African American

Native American or Alaskan Native (Inuit)

Native Hawaiian or Other Pacific Islander

One Race, Other

Two or More Races, Other

PLEASE SELECT YOUR ETHNIC CATEGORY

Please choose one

Ethnic Category

Hispanic or Latino

Not Hispanic or Latino

ARE YOU RECEIVING ANY ASSISTANCE?

Please select ALL boxes that apply to ANY ASSISTANCE your family is receiving.

Type of Assistance Received

Child Support

CHIP

WIC

CSFP

FoodShare Wisconsin

SNAP (Food Stamps)

FMLA

Medicaid

SSI

SSDI

VA Disability

TANF

WHEAP

WisWAP

Tribal Per Cap

Workers Comp

NONE

EMPLOYMENT STATUS

Are you currently employed?

Yes

No

TOTAL ANNUAL HOUSEHOLD INCOME

Total Income

Less than $10,000

$10,000 - $19,999

$20,000 - $29,999

$30,000 - $39,999

$40,000 - $49,999

$50,000 - $59,999

$60,000 - $69,999

$70,000 - $79,999

$80,000 - $89,999

$90,000 - $99,999

$100,000 - $124,999

$125,000 - $149,999

$150,000 or more

NONE

Was there an emergency situation which caused you to contact us?

Yes

No

Briefly explain your current situation:

How will receiving personal and home cleaning products help you?

If you have received cleaning products from us in the past, how has receiving these products helped you?

May we use the information you have provided in the 2 questions above about HOW WILL and HOW DID receiving cleaning products help? ONLY the information from these 2 areas will be shared to help us show potential donors your need is real.

Yes

No

PERSONAL CARE AND CLEANING PRODUCTS

The current Household Box contains the products listed below. IF YOU QUALIFY, WOULD YOU LIKE A BOX?

Yes

No

CLIENT ACKNOWLEDGEMENT

I certify that I am a member of the household listed above, 18 years of age or older, and certify that all information regarding my household is true to the best of my knowledge.

NOTE: Your answers on this form are important to help determine how to best serve you, and to obtain funding to support our programs.

All applicants MUST sign this form digitally.

Client Signature

Date

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Contact

460 E Pheasant Run
Oak Creek, WI 53154

office@givingtothenations.org

Monday, Tuesday, Friday

10am-4pm CST

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