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Step 1 of 7 - Contact Information

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Date*
MM slash DD slash YYYY
Your Contact Information
Name*
First Last
Phone
Do you text?
- Yes
- No
- I'm Not Sure
Email
Social Security Number*
Date of Birth*
MM slash DD slash YYYY
Current Address
Street Address Address Line 2 City State ZIP Code
Emergency Contact Information
Name
Phone
Do they text?
- Yes
- No
- I'm Not Sure
Relationship to you

Race*
- White
- Hispanic
- Asian
- Native American
- African American
- Multi-Race
We do not discriminate against any race, color, ethnicity, sex, sexual orientation, or disability.
Health
Health Condition*
- Good
- Fair
- Poor
Do you need any medical attention?*
- Yes
- No
Do you have any Mental Health problems?*
- Yes
- No
Do you have any Substance Abuse problems?*
- Yes
- No
- Alcohol
- Drugs
- Alcohol & Drugs
Do you have a long-term disability?*
- Yes
- No
- Physical
- Mental
- Both Physical and Mental
Employment
Are you employed?*
- Yes
- No
- Actively searching for a job
How many hours per week are you working?
How long have you had your current job?
Type of job
- Permanent
- Temporary
- Seasonal
Are you registered as a sex offender?
- Yes
- No
- Yes, and I need to comply with the 2,000 FT rule
Tell us about your household (if applicable)
Household member 1 name
Relationship
Date of birth
MM slash DD slash YYYY
Sex
- Male
- Female
Race
- White
- Hispanic
- Asian
- Native American
- African American
- Multi-Race
Household member 2 name
Relationship
Date of birth
MM slash DD slash YYYY
Sex
- Male
- Female
Race
- White
- Hispanic
- Asian
- Native American
- African American
- Multi-Race
Household member 3 name
Relationship
Date of birth
DD slash MM slash YYYY
Sex
- Male
- Female
Race
- White
- Hispanic
- Asian
- Native American
- African American
- Multi-Race
Current Need
What services are you in need of today?*
What is the reason you are currently seeking support?*

Homelessness
Are you currently homeless?*
- Yes
- No
Have you received help from MCHC in the past?
- Yes
- No
Month and year of last time you received help

If you do not remember the exact date, please estimate the month and year.

I am in need of*
- Rental Assistance
- Emergency Housing

Rental Assistance
Please fill in this section only if you are applying for rental assistance
I am seeking support for
- 1st Month Rent / Deposit
- On-going Rent
1st Month Rent / Deposit Starting on
MM slash DD slash YYYY
Ongoing Rent Starting on
MM slash DD slash YYYY
Landlord info
(Where payments will be sent)
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Plans for continued rent payment in future

Emergency Housing
Please fill in this section only if you are applying for emergency housing
I am seeking emergency housing for

Please enter the number of people that need emergency housing
For how many days?
If approved for emergency housing, what is your plan after this?
Please list any other sources of support you currently have
Do you smoke?
- Yes
- No

Client Release*
I certify that the above information is true and complete. I authorize MCHC to acquire and share information with partner agencies when required to seek out additional resources.

Special Thanks To

United Way of Mahaska County

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