MLK – Hosea Helps

Are you or anyone in your household interested in a FREE Mammogram?

Primary Agency Providing Services

Agency's Name

The Date

Month

Date

Year

These entries reflect preregistration.

Date of the event they preregistered for.

Basic Information

Prefix

First Name

Last Name

Email Address

Mobile Phone Number

Street Address

Unit Number

City

State

Select a Georgia County

Other Province

Zip Code

Country

Program Information

Assign a Case Manager

Case Status

Case Manager's Name

Services Requested

Summary of Services Provided

Additional Information

Demographics

Off On

Household

Off On

Identification

Off On

Barriers

Off On

Income

Off On

Expenses

Off On

Testimony

Off On

Add Notes

Off On

Add Tasks

Off On

Individual Service Plan

Food and Beverages

Off On

Financial Assistance

Off On

Goods and Products

Off On

Employment Assistance

Off On

Medical Care

Off On

Referral for Services

Off On

Training

Off On

Request SNAP Benefits

Off On

Contributing Partners

Off On

Home Delivery

Off On

Demographics

Low-Income Household

Yes

No

Ethnicity?

Gender?

Female

Male

Transgender Male to Female

Transgender Female to Male

Military Veteran?

Yes

No

Employed?

Yes

No

Retired

Status of Your Resume?

Currently Seeking Employment?

Ever Been Homeless?

Yes

No

Survivor of Domestic Violence?

Yes

No

Are you currently experiencing domestic violence?

Current Housing Status?

Receiving Food Stamps?

Yes

No

Use Public Transportation Weekly?

Yes

No

Have a Disabling Condition?

Yes

No

Have Health Insurance?

Yes

No

Household Snapshot

Total People in Household

Up to 14 People. At least 1 Person.

Total Minors Under 18

Up to 10 Minors. If None Type 0.

Total Seniors 55 and Older

Up to 6 Seniors. If None Type 0.

Are you at risk of being evicted?

At risk of utilities being disconnected?

Home Delivery

Home Delivery Program Name

Total Number of Meals Requested

Delivery Time Range

Order Date

Delivery Date

Important Delivery Notes

Add a Child

First Name

Last Name

This Child's Age Range

Gender

Grade Level

School Name

What type of toys does this child like?

Add Another Child Remove this Child

Identification

Birth Month

Birth Date

Birth Year

Social Security Number

Driver's License: FRONT

Maximum file size: 516MB

Driver's License: BACK

Maximum file size: 516MB

Social Security Card: FRONT

Maximum file size: 516MB

Social Security Card: BACK

Maximum file size: 516MB

Select any options that currently impact your household.

Alcohol Abuse

Developmental Disability

Drug Use

HIV/AIDS

Mental Health

Chronic Health Condition

Anger Management

Monthly Income

Employment Status

Employed by Employer

Self-Employed

Both Employed and Self-Employed

Unemployed

Add an Employer

Employer's Business Name

Employer's Contact Name

Employer's Contact Phone Number

Hours Worked Weekly from Job

Hours

Pay Each Hour from Job

$USD

Monthly Income from Employer

$Each Month

How often are you paid from your job.

Add Another Employer Remove this Employer

Add a Source of Self-Employment

Monthly Income from Self-Employment

$Each Month

Add details about your self-employment.

Single line text only. No paragraphs.

Add Another Source Remove this Source

Additional Monthly Income

Receiving Alimony?

Yes

No

Monthly Income from Alimony

$USD

Receiving Child Support?

Yes

No

Monthly Income from Child Support

$USD

Receiving Food Stamps?

Yes

No

Monthly Income from Food Stamps

$USD

Receiving Pension from Employment?

Yes

No

Monthly Income from Pension from Employment

$USD

Receiving Private Disability Insurance?

Yes

No

Monthly Income from Private Disability Insurance

$USD

Receiving Retirement Benefits?

Yes

No

Monthly Income from Retirement Benefits

$USD

Receiving Social Security?

Yes

No

Monthly Income from Social Security

$USD

Receiving Social Security Insurance (SSI)?

Yes

No

Monthly Income from Social Security Insurance (SSI)

$USD

Receiving Social Security Disability Insurance (SSDI)?

Yes

No

Monthly Income from Social Security Disability Insurance (SSDI)

$USD

Receiving TANF?

Yes

No

Monthly Income from TANF

$USD

Receiving VA Service Related Disability?

Yes

No

Monthly Income from VA Service Related Disability

$USD

Receiving VA Non-Service Related Disability?

Yes

No

Monthly Income from VA Non-Service Related Disability

$USD

Receiving Worker's Compensation?

Yes

No

Monthly Income from Worker's Compensation

$USD

Are you receiving any contributions toward your rent from outside the household?

Yes

No

Monthly Income from these Contributions

$USD

Describe the source of these monthly contributions toward your rent.

Single line text only. No paragraphs.

Receiving any other cash income?

Yes

No

Monthly Income from this Cash Income

$USD

Describe this Other Cash Income.

Single line text only. No paragraphs.

Receiving any other non-cash income?

Yes

No

Monthly Income from this Non-Cash Income

$USD

Describe this Other Non-Cash Income.

Single line text only. No paragraphs.

Total Monthly Income

Combined Monthly Income

$USD

From Employment

$USD

From Self-Employment

$USD

From Additional Sources

$USD

Monthly Expenses

Pay Rent or Mortgage?

Rent

Mortgage

No

Rent or Mortgage Paid To

Monthly Amount Paid in Rent or Mortgage

$USD

Landlord or Owner's Complete Address

Example: 3645 Habersham Rd NE, Atlanta, GA 30305

Landlord or Owner's Email Address

Landlord or Owner's Phone Number

Do you pay any of the following utility bills?

Amount Paid Toward Electricity

$Each Month

Amount Paid Toward Gas

$Each Month

Amount Paid Toward Water

$Each Month

Amount Paid Toward Phone

$Each Month

Do you pay for child care?

Yes

No

Amount Paid Toward Child Care

$Each Month

Do you have any other monthly expenses?

Yes

No

Total Amount of Other Monthly Expenses

$Each Month

Describe these other monthly expenses.

Single line text only. No paragraphs.

Total Monthly Expenses

Combined Monthly Expenses

$USD

Amount of Funds Available Each Month After Expenses

Funds Available After Expenses

$USD

Testimony

Upload Up to 5 Photos

Maximum file size: 516MB

Upload a Short Video

Maximum file size: 516MB

Upload a Written Testimony

Maximum file size: 516MB

Type a Testimony as Plain Text

Single line text only. No paragraphs.

Food and Beverage Distribution

Food Source

Enter the name of the other food source.

Type of Food Package

Select a Hosea Helps' Food Package

Hosea Helps' Package Cash Value

Name this other food package.

Other Package's Cash Value

$USD

Describe this other food package.

Single line text only. No paragraphs.

Add Another Food Item Remove this Food Item

Total Value of Food Distributed

Combined Value of Food for this Client

$USD

Do not edit.

Total Value of Hosea Help's Packages

$USD

Do not edit.

Total Value of Other Packages

$USD

Do not edit.

Financial Assistance

What financial assistance did we provide?

Value of Financial Assistance

$USD

Funding Source

Grant Title

Check Number from Accounting

Add More Financial Assistance Remove this Financial Assistance

Total Value of Financial Assistance Provided

Combined Value of Financial Assistance for this Client

$USD

Do not edit.

Good and Products

Type of Product

Value of Goods and Products

$USD

Describe these products.

Single line text only. No paragraphs.

Add More Products Remove this Product

Total Value of Good and Products Distributed

Combined Value of Goods and Products for this Client

Do not edit.

Employment Assistance

Type of Employment Assistance

Value of Employment Assistance

$USD

Describe the Employment Assistance that was Provided

Single line text only. No paragraphs.

Add More Employment Assistance Remove this Employment Assistance

Total Value of Employment Assistance Provided

Combined Value of Employment Assistance Provided to this Client

$USD

Do not edit.

Medical Care

Type of Medical Care

Value of Medical Care Provided

$USD

Name of the Hospital

Add More Medical Services Remove this Medical Service

Total Value of Medical Care Provided

Combined Value of Medical Care Provided to this Client

Do not edit.

Referral for Services

Name of the Agency Where Client was Referred

Add Value

Reason for Referral

Single line text only. No paragraphs.

Value of Referral for Services

$USD

Do not edit.

Record an Outcome?

Enter the Outcome Here

Single line text only. No paragraphs.

Add Another Referral Remove this Referral

Basis for Value of Referral for Services

Average Cost of Case Management Per Hour

$USD

Average Cost of Case Management Per Minute

Do not edit.

Making the Referral

Minutes

Following Up

Minutes

Total Minutes Spent on this Referral

Minutes

Do not edit.

Total Value of Referrals Provided

Combined Value of Referrals Provided to this Client

$USD

Do not edit.

Training

Type of Training

Add Other Type of Training

Who conducted this training?

Add multiple trainers each separated by a comma.

Describe this training.

Value of Training

$USD

Add More Training Remove this Training

Total Value of Training Provided

Combined Value of Training Provided to this Client

$USD

Request SNAP Benefits

Select any benefits you would like to apply for.

Contributing Partners

Name of the Partner Agency

Value of this Contribution

$USD

Describe this partners contribution.

Add Another Partner Remove this Partner

Total Value of Contributed by Partners

Combined Value of Contributions by Partners

$USD

Total Value of All of the Services Provided

Combined Value of All of the Services Provided to this Client

$USD

Case Management

What is the status of this case?

Initial Contact Made

Discontinued After Initial Contact

Screening In Progress

Discontinued After Screening

Case Open, ISP Active

One or More Program Goals Failed, Case Closed

Missing Copy of Check

Program Goals Met, Case Closed

Describe the program goals that failed and why.

Single line text only. No paragraphs.

Flag this Case

Demands Immediate Attention

Missing Required Documentation

Case Transferred to Another Manager

Client Filed a Customer Service Complaint

Client has been Banned

Why does this case demand immediate attention?

Single line text only. No paragraphs.

What documentation is missing?

Single line text only. No paragraphs.

How many times has this case been transferred?

A case can only be transferred twice.

Who originally had this case, and who was it transferred to?

You can only transfer this case one more time.

Who most recently had this case, and who was it transferred to?

You cannot transfer this case any more times.

What is the client's customer service complaint?

Single line text only. No paragraphs.

Why was this client banned?

Single line text only. No paragraphs.

Follow Up

30 Days Follow Up Complete

60 Days Follow Up Complete

90 Days Follow Up Complete

Count from the application date.

Program success at 30 days?

What is the result of the 30 day follow up?

Single line text only. No paragraphs.

Program success at 60 days?

What is the result of the 60 day follow up?

Single line text only. No paragraphs.

Program success at 90 days?

What is the result of the 90 day follow up?

Single line text only. No paragraphs.

Case Notes

Add Case Notes Here

Single line text only. No paragraphs.

Add a Task

Task Status

Enter Task Here

Enter the details of this task.

Single line text only. No paragraphs.

Enter the results of this task.

Single line text only. No paragraphs.

Add Another Task Remove this Task

Administrative Panel

Enter your first and last name.

MLK Jr. Holiday Festival 2026

Groceries, School Supplies, Free Health Care and More . . .

Monday, January 19th at 11:00 AM

Primary Agency Providing Services

The Date

Basic Information

Program Information

Services Requested

Summary of Services Provided

Additional Information

Individual Service Plan

Demographics

Household Snapshot

Home Delivery

Add a Child

Identification

Select any options that currently impact your household.

Monthly Income

Add an Employer

Add a Source of Self-Employment

Additional Monthly Income

Total Monthly Income

Monthly Expenses

Total Monthly Expenses

Amount of Funds Available Each Month After Expenses

Testimony

Food and Beverage Distribution

Total Value of Food Distributed

Financial Assistance

Total Value of Financial Assistance Provided

Good and Products

Total Value of Good and Products Distributed

Employment Assistance

Total Value of Employment Assistance Provided

Medical Care

Total Value of Medical Care Provided

Referral for Services

Basis for Value of Referral for Services

Total Value of Referrals Provided

Training

Total Value of Training Provided

Request SNAP Benefits

Contributing Partners

Total Value of Contributed by Partners

Total Value of All of the Services Provided

Case Management

Case Notes

Add a Task

Administrative Panel arrowup6

Thank you!

Administrative Panel