INITIAL SCREENING FORM

*Please Read Instructions before filling out Initial Screening Form.

INSTRUCTIONS:

  • If you are seeking assistance, please fill out the form below.

  • After consideration of provided information, you will be contacted regarding eligibility of appointment. Please make sure the phone number you provide is correct as we will make two (2) phone calls. If unable to reach you, it is your choice to complete another initial screening form.

  • You MUST bring all required documents to your scheduled appointment. If you do not bring all the required documents, you will not be seen by a caseworker.

  • An appointment does not guarantee assistance. Assistance is determined by availability of funds, your circumstances, and proper documentation.

  • Once the screening form is submitted, your case will be reviewed, and you will be contacted by the phone number you have provided within 1 to 2 business days. If you have not received notification within 3 business days, please call our client line:

    Client Line: 940-565-5479

    Monday-Friday 8am-11:30am & 1:00pm-3:30pm

Name *
Name
Address *
Address
Phone *
Phone
Yes or No
Example: Utilities, Eye Exam, Etc.
(within past 60 days) leading you to seek assistance?