2023-24 MOHCD Client Intake Form - English

.docx
School
Harvard University **We aren't endorsed by this school
Course
ANTHROPOLO MISC
Subject
Sociology
Date
Nov 12, 2023
Pages
3
Uploaded by hbsns2 on coursehero.com
First Name: Last Name or Client ID: Street Address: City: State: Zip Code: Phone Number (Optional) : Email Address: Date of Birth: / / ( Optional ) 1. Race and Ethnicity Which best describes your race/ethnicity? (Mark ALL check boxes that apply) Indigenous American Indian/Native American (Specific Group: ) Indigenous from Mexico, the Caribbean, Central America or South America (Specific Group: ) Other Indigenous Asian Chinese Filipino Japanese Korean Mongolian Central Asian South Asian Southeast Asian Other Asian Latino Caribbean Central American Mexican South American Black African African American Caribbean, Central American, South American or Mexican Other Black Middle Eastern/West Asian or North African North African West Asian Other Middle Eastern or North African Pacific Islander Chamorro Native Hawaiian Samoan Other Pacific Islander 2. Gender Identity and Sexual Orientation What is your gender? (Mark the ONE that best describes your current gender identity) Fema le Male Genderqueer/Gender Non- Binary Trans Female Trans Male How do you describe your sexual orientation or sexual identity? (Mark ONE ) Bisexual Gay/Lesbian/Same-Gender Loving Questioning/Unsure Straight/Heterosexual Not Listed. Please Specify: Decline to Answer By what name do you wish to be called? (Optional) Mayor's Office of Housing & Community Development (MOHCD) MOHCD Client Intake Form Review this form with client and complete all items Refer to the instruction sheet to help with form completion 3. Keep on file for five years Fiscal Year 2023- 24
3. Language What is your primary language spoken at home? (Mark ONE) Chinese - CantoneseRussian Chinese - MandarinSpanish EnglishVietnamese FilipinoOther Language. Please Specify: What gender pronouns do you use? [Optional] (Mark ONE) She/Her/Hers They/Them/Theirs He/Him/His Not Listed. Please Specify: 4. Veteran and Disability Status _________________________________________________________________________________________________ Are you a veteran? Yes No Are you a person with a disability? Yes No 5. Family Size and Income 6. Income Certification I hereby certify that, to the best of my knowledge, the above statements are true and correct. I understand this information is subject to verification only by authorized U.S. Department of Housing & Urban Development (HUD) officials for federally-funded grants. CLIENT INTERVIEWER Client Printed Name Interviewer Printed Name Parent/Client Signature Date Interviewer Signature Date Which best describes your family? A family includes a single person or a group of people living together. (Mark ONE) Single Headed Family Dual Headed Family Number of persons living in your family (including yourself): Estimated income for next 12 months for all adult members: $ Do you receive any type of public benefits assistance? (Mark ALL that apply) CalWorks CalFresh Cash Assistance Linked to Medi-Cal (CALM) Cash Assistance Program for Immigrants (CAPI) County Adult Assistance Program (CAAP) Medi-Cal Refugee Cash Assistance Social Security Disability Insurance (SSDI) Supplemental Security Income (SSI) What source(s) of information were used to verify your income? (Mark ALL that apply) Public Benefits (mark here if you chose any option to the left) Payroll Stub Tax Return Unemployment Benefits Veteran's Benefits Rental Assistance (e.g., Section 8 voucher) Placed in Foster Care Self-Certified. Please explain:
MOHCD collects data on race, ethnicity, sexual orientation and gender identity, in order to ensure the programs and services we fund are addressing the needs of the vulnerable communities we serve, and to report anonymous information to key funders like HUD. MOHCD protects your personally identifiable information (PII) from loss, theft, misuse and unauthorized access and disclosure. PII includes your name, address, birthdate, race and ethnicity, gender, sexual orientation/identify, and household size and income. Also, PII is never included in reports, public documents or public websites, and can only be seen by authorized persons when it's necessary to achieve the purposes noted above.
Page1of 3
Uploaded by hbsns2 on coursehero.com