Child (0-18)_____

Adult (19-64)_____
Senior (65+)_____
B___ W___ H___ O___
Male_____ Female_____
Catholic_____ Non-Catholic____ Poverty Level:____

ST. PETER OF ALCANTARA CLIENT INTAKE/INTERVIEW SHEET
Client Name:________________________________________
Address:________________________________

Today’s Date:__________________

City: Pt Washington State: NY

Zip: 11050

Telephone:__________________

Cell Phone: ______________

Social Security:___________

Date of Birth:________________

Marital Status:___________

Legal Status:_____________

How Long at Current Address:________

Prior Address:__________________________________

Address Verification: (Specify Form of Verification):_______________________

Copy for File:____

Landlord/Mortgage Lender (Name & Phone):_____________________________________________
Referred By (if Applicable):_____________________________________________________________
Today’s Request/Immediate Need:_______________________________________________________
DSS Case Number (if Applicable):________________________________________________________
DSS/Caseworker Name & Phone:________________________________________________________
Member of Household Living with you:
Name

1.
2.
3.
4.
5.
6.
7.
Comments:

Relationship

Date of Birth

SS #

School (If Applicable)

BUDGET/FACT SHEET
Client Name:________________________________________
INCOME

Date of Birth:__________________
MONTHLY / ARREARS

EXPENSES
NET Monthly Salary
Husband
Wife
Other
Social Security Benefits
Retirement/Husband
Retirement/Wife
SSD (Disability)
SSI
Other_________________
______________________

$________
$________
$________
$________
$________
$________
$________
$________

Section 8 Subsidy:

$_________

Dept. of Social Services (DSS)
Cash Grant
Shelter Grant
Food Stamps:

$_________
$_________
$_________

Veteran’s Benefits
$_________
Workman’s Comp
$_________
Pension
$_________
Unemployment Ins.
$_________
Effective Dates: from_______ to _________
Child Support
$_________
Other Source of Income
$_________
Describe_____________________
Medicaid/Medicare___________
List Those Covered:
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________

TOTAL INCOME:

Housing
Rent
Mortgage
Property/Taxes

$_______________
$_______________
$_______________

Household Expenses
Food
Oil/Kepyspan
LIPA
Water
Cable
Telephone
Outstanding Credit
Car Loan/Lease
Personal Loan
Credit Cards/Total
Home Equity Loan

$_______________
$_______________
$_______________
$_______________
$_______________
$_______________
$_______________
$_______________
$_______________
$_______________
$_______________

Transportation
____________________ ◄ Make/Model/Year
Car Insurance
$_______________
Gas/Maintenance
$_______________
Public Transit
$_______________
Other
$_______________
Medical
Health Ins. Premium
Medications
Co-Pays
Hospital Bills
Other_____________

$_______________
$_______________
$_______________
$_______________
$_______________

Child Care
$_______________
Laundry/Personal Care $_______________
Misc./Other
$_______________
List:________________
________________
________________
$___________

TOTAL EXPENSES

$________________