Page 3 - Application for Services
P. 3

SERVICES AND PROGRAMS
                                                                                    APPLICATION FOR SERVICES
                                                                                   Paper version for field intakes


               Status:                           Restrictions:
               Time served:                      Length of parole:
               Parole/probation terms/requirements:

               Comments/notes:

               Type:                             Level:                         Approx. date:
               Status:                           Restrictions:

               Time served:                      Length of parole:
               Parole/probation terms/requirements:

               Comments/notes:


               BACKGROUND: OTHER

                Participant has a history of substance abuse        Participant receives in-home living assistance
                Participant is an at-risk youth                 Participant is a youth currently in foster care


               HOUSEHOLD & INCOME: HOUSEHOLD
               Housing type:                                     Marital status:
               Total number in household:                        Number of dependents:


               HOUSEHOLD & INCOME: INCOME - INDIVIDUAL
               Please enter income received over the past 30 days.

               $           Monthly income – wages/salary          $            Monthly income – MFIP/TANF
               $           Monthly income – SSI                   $            Monthly income - GA
               $           Monthly income - SSDI                  $            Other:


               HOUSEHOLD & INCOME: NON-CASH BENEFITS

               $           Received monthly from housing subsidy    Or, receives subsidy of unknown amount
               $           Received monthly from SNAP/MFIP food   Has received SNAP in last three years
                Has health insurance through employer             Has MA, MN Care, MNsure






               GESMN-Internal Use Only | Revised 10/23/2019                                            Page 3
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