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On Hosea Williams
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Frequently Asked Questions
Using the Brand
Human Services: Clients Mommy and Me
Mommy and Me Event Terms of Agreement
For Mothers and Expecting Mothers
*
I understand that this event is for women who have newborn babies, infants and toddlers and for women who are pregnant.
While Supplies Last
*
This event starts at 11 AM. Even though you register online, you will only be able to pick up items while supplies last. So do not arrive too late or you risk not being able to receive certain items.
Drive-Thru Only Event
*
To keep everyone safe during COVID this event is strictly a Drive-Thru event. To receive items, you must be in a vehicle.
Signature Events Standard Terms of Agreement
While Supplies Last
*
The event starts at 11 AM. Even though you registered you will only be able to pick up food while supplies last. So do not arrive too late or you will risk not being able to get any groceries.
Must be in a vehicle.
*
To keep everyone safe during COVID this event is strictly a Drive-Thru event. To receive groceries, you must be in a vehicle.
Primary Agency Providing Services
Agency's Name
Hosea Helps
The Date
Month
*
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January
February
March
April
May
June
July
August
September
October
November
December
Date
*
Year
*
- Select -
2021
2022
2023
2024
2025
Basic Information
Prefix
*
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Ms.
Mrs.
Mr.
First Name
*
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*
Email Address
*
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*
Street Address
*
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Select a Georgia County
*
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*
Country
Afghanistan
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Brazil
British Indian Ocean Territory
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New Caledonia
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Niger
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North Korea
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Norway
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Poland
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Puerto Rico
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Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
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Senegal
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Seychelles
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Singapore
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Slovakia
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Somalia
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South Georgia and the South Sandwich Islands
South Korea
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Spain
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Sweden
Switzerland
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Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Program Information
Assign a Case Manager
No
Yes
Case Status
No Case Manager Assigned
Case In Progress
Case Suspended
Case Cancelled
Case Successfully Closed
Case Manager's Name
*
Select Relevant Programs
Day Center
Financial Assistance
COVID Response
Community Distribution
Community Education
Outreach to the Homeless
Disaster Relief
Fresh Food Wednesdays
Mommy and Me
Thanksgiving Event
Christmas Event
Children's Christmas Event
MLK Jr. Holiday
Spring Event
No Summer Hunger
Back to School
DeKalb District 7
Services Requested
Select any services this household needs.
Baby Items
Blankets
Clothing
Counseling or Rehabilitation
Emergency Shelter
Employment Assistance
Food and Beverages
Get or Renew Food Stamps
Medical Care
Rent Assistance
School Supplies
Toiletries
Toys
Utility Assistance
Summary of Services Provided
Mark any services that were provided.
Baby Items
Barber and Beauty Services
Clothing and Accessories
Community Education
Employment Assistance
Food and Beverages
Homeless Prevention Screening
Medical Services
Personal Care Items
Referral to Another Agency
Rent Assistance
School Supplies
SNAP Screening
Toys
Training
Utility Assistance
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
Demographics
Low-Income Household
Yes
No
Resident of the City of Atlanta
Yes
No
Age 55 Years or Older?
Yes
No
Have a Savings Account?
Yes
No
Ethnicity?
*
African-American/Black
American Indian
Asian
Hawaiian/Pacific Islander
Hispanic
White/Caucasian
Gender?
*
Female
Male
Transgender Male to Female
Transgender Female to Male
Is anyone in your household currently pregnant?
- Select -
Yes
I'm not sure.
No
US Citizen or Legal Immigrant?
Yes
No
Student?
Yes
No
Military Veteran?
*
Yes
No
Employed?
*
Yes
No
Retired
Status of Your Resume?
- Select -
I don't know how to make a resume.
I know how to make one, but I haven't.
No, I don't have one.
Yes, I have one, but it needs to be updated.
Yes, I have one.
Currently Seeking Employment?
- Select -
No
Yes. I am unemployed seeking employment.
Yes. I am employed seeking better employment.
Ever Been Homeless?
Yes
No
Survivor of Domestic Violence?
Yes
No
Are you currently experiencing domestic violence?
- Select -
I am currently homeless because I am fleeing domestic violence.
I am currently experiencing domestic violence.
I have experienced domestic violence within the past year.
I am not currently experiencing domestic violence.
Marital Status?
- Select -
Single
Engaged
Married
Separated
Divorced
Widowed
Current Housing Status?
- Select -
At risk of losing my housing.
Homeless: Living on the Street
Homeless: Living in a Vehicle
Homeless: Living in a Shelter
Homeless: Living in a Hotel
Homeless: Living in Transitional Housing
Living with family and friends.
Stable in my own home.
Free or Reduced School Lunch?
Yes
No
Receiving WIC Benefits?
Yes
No
Receiving TANF?
Yes
No
Receiving Food Stamps?
Yes
No
Receiving Section 8 Benefits?
Yes
No
Use Public Transportation Weekly?
Yes
No
Have a Disabling Condition?
Yes
No
Have Health Insurance?
Yes
No
Select any disabilities that apply to you.
Blind
Hearing Impaired
Inability to Walk
Loss of a Limb
Cognitive Disorder
Chronic Pain
Type of Health Insurance?
Private: COBRA
Private: Employer
Private: Individual
State Children's Health Program
Medicaid
Medicare
Military Insurance
Native American Services
Other Public Insurance
None of the Above
Household Snapshot
Total People in Household
*
Total Minors Under 18
*
Total Seniors 55 and Older
*
Are you at risk of being evicted?
- Select -
Yes
No
At risk of having your utilities disconnected?
- Select -
Yes
No
Add Children's Information
Yes
No
Add a Child
First Name
Last Name
Age
- Select -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Gender
- Select -
Girl
Boy
Grade Level
- Select -
Pre-School
1st Grade through 5th Grade
6th Grade through 8th Grade
9th Grade through 12th Grade
School Name
Add Another Child
Remove this Child
Identification
Birth Month
- Select -
January
February
March
April
May
June
July
August
September
October
November
December
Birth Date
- Select -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year
- Select -
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Social Security Number
Driver's License: FRONT
Drop a file here or click to upload.
Choose File
Maximum upload size: 134.22MB
Driver's License: BACK
Drop a file here or click to upload.
Choose File
Maximum upload size: 134.22MB
Social Security Card: FRONT
Drop a file here or click to upload.
Choose File
Maximum upload size: 134.22MB
Social Security Card: BACK
Drop a file here or click to upload.
Choose File
Maximum upload size: 134.22MB
Select any options that currently impact your household.
Alcohol Abuse
- Select -
Yes
Yes, Receiving Treatment
Yes, Condition is Indefinite
No
Developmental Disability
- Select -
Yes
Yes, Receiving Treatment
Yes, Condition is Indefinite
No
Drug Use
- Select -
Yes
Yes, Receiving Treatment
Yes, Condition is Indefinite
No
HIV/AIDS
- Select -
Yes
Yes, Receiving Treatment
Yes, Condition is Indefinite
No
Mental Health
- Select -
Yes
Yes, Receiving Treatment
Yes, Condition is Indefinite
No
Chronic Health Condition
- Select -
Yes
Yes, Receiving Treatment
Yes, Condition is Indefinite
No
Anger Management
- Select -
Yes
Yes, Receiving Treatment
Yes, Condition is Indefinite
No
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.
- Select -
Weekly
Bi-Weekly
Monthly
Quarterly
Every 6 Months
Annually
Other
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?
Electric
Gas
Water
Phone
None
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 (Optional)
Upload Up to 5 Photos (Optional)
Drop a file here or click to upload.
Choose File
Maximum upload size: 134.22MB
Upload a Short Video (Optional)
Drop a file here or click to upload.
Choose File
Maximum upload size: 134.22MB
Upload a Written Testimony (Optional)
Drop a file here or click to upload
Choose File
Maximum upload size: 134.22MB
Type a Testimony as Plain Text (Optional)
Single line text only. No paragraphs.
Food and Beverage Distribution
Food Source
Hosea Helps
City of Atlanta
DeKalb County
Fulton County
Other
Enter the name of the other food source.
Type of Food Package
Hosea Helps Preset Package
Other Package
Select a Hosea Helps' Food Package
Adult Diapers
Aluminum Pans
Apple Sauce
Apples: Fresh Whole
Arm Chair: Single Person
Art Set
Assorted: Bread
Assorted: Canned Goods
Assorted: Dairy
Assorted: Desserts
Assorted: Dry Goods
Assorted: Fruit
Assorted: Meat
Assorted: Produce
Assorted: Vegetables
Baby: Bibs
Baby: Blankets
Baby: Bottle Brushes
Baby: Bottle Nipples
Baby: Bottles
Baby: Diapers
Baby: Formula
Baby: Gloves and Mittens
Baby: Hats
Baby: Onesies
Baby: Shoes
Baby: Socks
Baby: Teething Rings
Baby: Wipes
Bags: Fabric Grocery
Bar Soap
Basketball
Bassinet: MiClassic
Bassinet: Mika Micky
Batteries: 24PK
Batteries: 8PK
Binders
Blankets
Bleach
Body Lotion
Body Wash
Book Bags
Bookshelf
Boxes: 10 in. x 8 in. x 6 in.
Boxes: 12 in. x 9 in. x 5 in.
Boxes: 16 in. x 10 in. x 12 in.
Boxes: 20 in. x 20 in. x 20 in.
Boxes: 24 in. x 18 in. x 18 in.
Boxes: 9 in. x 9 in. x 9 in.
Boxes: Mixed Sizes
Bread: Biscuits
Brooms: Standard Sweep
Brown Sugar
Bulk: Frito Lay Chips L
Bulk: Frito Lay Chips Small
Bulk: Gloves and Mittens
Bulk: Hoodies
Bulk: Jackets
Bulk: Pants
Bulk: Socks
Bulk: T-Shirts
Candle
Canned: Beans
Canned: Fruit
Canned: Meat
Canned: Soup and Chili
Canned: Vegetables
Car: Toy
Carrots: Fresh Whole
Case: Sunny Delight
Cat Food: Bags
Cat Food: Can
Cereal
Chairs: Banquet
Chairs: Folding Metal
Charger Plates: Ceramic
Christmas Tree: Artificial
Christmas Tree: Real
Clothing
Coffee
Coffee Filters
Computer Keyboards
Computer Monitors
Computer Mouses
Conditioner
Copy Paper
Cornbread Mix
Cotton Swabs
Cranberry Sauce
Crayon: 24ct
Cups: Disposable
Deodorant
Desk
Dessert: Tea Cake Cup
Dish Soap
Disinfectant Solution
Disinfectant Wipes
Dog Food: Bag
Dog Food: Can
Dolls: Toy
Drink: Powder
Dust Pans: Standard Short Handle
Easter Basket
Edger
Energy Drink
Erasers
Extension Cord
Face Masks
Face Shields
Flashlight
Flour
Folders
Food Bags: Goodr
Food Box Kit: 12.21.22
Food Box Kit: FFW 02.03.23
Food Box Kit: FFW 02.08.23
Food Box Kit: FFW 02.09.22
Food Box Kit: FFW 02.16.22
Food Box Kit: FFW 02.22.23
Food Box Kit: FFW 03.01.23
Food Box Kit: FFW 03.02.22
Food Box Kit: FFW 03.08.23
Food Box Kit: FFW 03.15.23
Food Box Kit: FFW 03.22.23
Food Box Kit: FFW 03.29.23
Food Box Kit: FFW 03.30.22
Food Box Kit: FFW 04.06.22
Food Box Kit: FFW 04.13.22
Food Box Kit: FFW 04.28.22
Food Box Kit: FFW 05.11.22
Food Box Kit: FFW 05.18.22
Food Box Kit: FFW 06.22.22
Food Box Kit: FFW 06.29.22
Food Box Kit: FFW 07.27.22
Food Box Kit: FFW 09.28.22
Food Box Kit: FFW 10.05.22
Food Box Kit: FFW 10.26.22
Food Box Kit: FFW 11.02.22
Food Box Kit: FFW 11.23.22
Food Box Menu: 07.14.22 Kids Meal
Food Box: 07.14.20
Food Box: 10.11.22
Food Box: B2S 06.01.2022
Food Box: CCP 2021
Food Box: CHR 12.1.2021
Food Box: Dekalb County
Food Box: ESR 2022
Food Box: Forrest Cove
Food Box: Lunch Box 5.1.2021
Food Box: MLK 1.1.2022
Food Box: THX 11.1.2021
Food Container: Cup or Bowl Style
Food Container: Hinged Lid, 3 Compartment
Football
Fork: Plastic
Fruit Cups
Fruit Snacks
Garden Hoe
Gift Card
Gift Card: Twenty-five Dollars
Glue
Gluestick
Goldfish Baked Crackers
Grits
Hamburger Helper
Hand Sanitzer
Hand Soap
Handwarmer
Headphones
Hello Fresh Meal 09.14.22
Highlighter
Hormel: Ham
Hot Wheels: Track
Index Cards: 100 Count
Jars
Jelly
Juice
Ketchup
Laptops
Laundry Detergent
Laundry Drying Machine
Laundry Washing Machine
Lawn Blower
Leash: Pet
Lip Balm
Markers
Meat: Bacon
Meat: Chicken Parts
Meat: Ground Beef
Meat: Ham
Meat: Sausage
Meat: Whole Chicken
Meat: Whole Turkey
Milk
Mops
Multipurpose Cleaner
Oatmeal
Oil
Paint
Pallet Truck: Standard
Pancake Mix
Paper Plates
Paper Towels
Pasta
Pasta Sauce
Pasta: Macaroni and Cheese
Pastries
Pastries: Donuts
Pastries: Fruit Bars
PCs
Peanut Butter
Peanut Butter Crackers
Peanuts
Pen
Pencil Sharpener
Pencils
Pepper
Petroleum Jelly
Pillow Cases
Pizza Sauce
Plastic Comb
Play Doh
Pop n Hop: Board Game
Pop-Tarts
Potato Chips
Potatoes: Mashed
Potatoes: Whole
Power Strip
PPE Kit: 02.25.21
Pretzels
Publix Grocery Plastic Bags
Raisins
Ramen Noodles
Razor
Refrigerator: French Door Stainless Steel
Remote Control Cars
Rice
Ruler
Salad Dressing
Sandwiches
Scissors
Seasoning
Seasoning: Salt
Seasoning: Sugar
Shampoo
Shaving Cream
Shoelaces
Shovel
Shower Cap
Slime: Toy
Soccer Ball
Soda
Space Heater: High End
Space Heater: Low End
Spiral Notebook
Sterno
Stove: Portable
Stuffed Animals
Stuffing Mix
Surgical Gloves
Swiffer Pads: 24 Count
Table: 6 in. to 8 in.
Table: Square 30 in. to 60 in.
Tablets
TB Disinfectant Cleaner
Tea Cakes/Biscuits
Tea: Bags
Tea: Pre-Made
Tent: 10x10
Thermometer: Non-Touch
Thermometer: Touch
Tofu
Toilet Paper
Toiletry Kit: 04.23.21
Toiletry Kit: 12.31.20
Toiletry Kits: Hosea Helps Single Use
Tomato Sauce
Toothbrushes
Toothpaste
Towels
Toy: Building Blocks
Trash Bags
Trash Can: Large
Trash Can: Medium
Trash Can: Small
TVs 32 in. and Below
TVs 43 in.
TVs 50 in.
TVs 65 in.
TVs 70 in. and Up
Umbrella
Wagon Cart
Wash Cloths
Water
Water Balloons
Wheel Chair
Women Pads
Women Underwear
Yahtzee: Board Game
Yams
Yard Rake
Hosea Helps' Package Cash Value
0.00
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?
- Select -
Emergency Direct Funds
Emergency Shelter
Employment Assistance (Paid For)
Mortgage Assistance
Moving Expenses
Rapid Rehousing
Rent Assistance
Transportation Assistance
Utility Assistance
Value of Financial Assistance
$
USD
Funding Source
Hosea Helps
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
- Select -
Clothing
Personal Care Items
School Supplies
Toys
Other
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
- Select -
Grooming and Cosmetics
Wardrobe and Uniforms
Employment Related Transportation
Scheduled Job Training
Scheduled a Job Interview
Employment Secured
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
- Select -
Medical Screening
On-Site Doctor's Visit
COVID Testing
Referral to a Hospital
Value of Medical Care Provided
$
USD
Name of the Hospital
Type of Screening
Biometric Screening
Blood Pressure
Blood Glucose
BMI or Obesity
Cholesterol
Cancer
HIV/AIDS
Mental Health
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
No
Yes
Reason for Referral
Single line text only. No paragraphs.
Value of Referral for Services
$
USD
Do not edit.
Record an Outcome?
No
Yes
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
Minutes
Following Up
Minutes
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
Basic Computer Hardware
Microsoft Office Suite
Software Training
Communication Skills
Other
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.
*
Food Stamps
TANF
Medicaid
CAPS
Medicare
Women's Health Coverage (Ages 19-44)
None of the Above
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?
- Select -
Once
Twice
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?
Yes
No
What is the result of the 30 day follow up?
Single line text only. No paragraphs.
Program success at 60 days?
Yes
No
What is the result of the 60 day follow up?
Single line text only. No paragraphs.
Program success at 90 days?
Yes
No
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
- Select -
Open
Closed
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
Date Stamp
Do not edit.
Time Stamp
Do not edit.
Interaction ID
Do not edit.
Client ID
Do not edit. Format: Last Name, First Name, Email
Human Services Staff Members
Accounting and HR
Customer Services
Development
Executive Management
Human Services
Logistics
Public Relations
Volunteer Services
Do not edit.
Hosea Helps Food Packages
No
Yes
Do not edit.
Total Tasks
Do not edit.
Total Children
Do not edit.
Household Children Minus Total Children
If you are human, leave this field blank.
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