SOCIAL SERVICES

The Zan Wesley Holmes Jr. Community Outreach Center, in partnership with St. Luke “Community” United Methodist Church and Warren United Methodist Church, offer assistance to individuals who are in need of social services help.

Please complete and submit this Pre-Intake Application so that we can assess the services of which you are in need such as food, gas card, temporary housing, etc.

Pre-Intake Application

Name

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email

Date of Birth

MM

DD

YYYY

Last 4 Digits of SSI

Marital Status

Spouse's Name (if married)

Spouse's Date of Birth (if married)

MM

DD

YYYY

Spouse's Last 4 Digits of SSI (if married)

Do you have children?

Yes

No

How many children do you have?

Are you working?

Yes

No

Do you have transportation?

Yes

No

Are you in any danger or do you feel threatened?

Yes

No

Do you need any Emergency assistance? If so, please explain the kind of assistance you need: temporary housing, gas card, food, utilities, counseling?

Who referred you to the Zan Holmes Center?