HHMI Client Care & Stabilization Intake Form

Before you begin

Confidentiality Statement

Your privacy matters to us. Horace Holmes Ministries, Inc. (HHMI) is committed to maintaining the confidentiality and dignity of every individual seeking assistance. Information collected through this intake process is used solely for ministry assessment, resource coordination, referrals, and assistance consideration.

Completion of this form does not guarantee assistance. All information provided must be truthful and complete. Email communication may not be fully confidential.

I have read and understand the confidentiality statement above.

Section 1

Eligibility & Residency

We primarily serve residents of Macon-Bibb County.

Are you currently a resident of Macon-Bibb County?

Yes No

How long have you lived in Macon-Bibb County?

Can you provide proof of residency?

Yes No

Have you previously received assistance from HHMI?

Yes No

If yes, please explain

Section 2

Personal Information

Full Legal Name

Date of Birth

Age

Gender

Male Female Prefer Not to Answer

Marital Status

Section 3

Contact Information

Street Address

Apartment / Unit

City

State

Zip

Home Phone

May we leave a message? Yes No

Cell Phone

May we leave a message? Yes No

Email Address Email communication may not be confidential.

May we email you? Yes No

Section 4

Household Composition

How many adults currently live in your household?

List all adults living in the household

Name	Relationship	Employed	Contributes Financially

If support is not being provided, please explain

Have you pursued Child Support Services? (household adults)

Yes No

If no, please explain

Section 5

Children & Support Systems

Number of Children Living in Household

List All Children

Child Name	Age	School	Grade

If support is not being provided, please explain

Have you pursued Child Support Services?

Yes No

If no, please explain

Section 6

Household Income

Please list all monthly household income.

Employment

Child Support

SNAP / EBT

SSI

Disability

TANF

Unemployment

Family / Friend Support

Other

Total Monthly Household Income

Section 7

Monthly Household Expenses

Rent / Mortgage

Utilities

Food

Transportation

Car Payment

Insurance

Childcare

Medical Expenses

Cell Phone

Internet / Cable

Other

Section 8

Current Crisis Information

What assistance are you requesting from HHMI?

When did this hardship begin?

What caused your current hardship?

Have you experienced this hardship before?

Yes No

What steps have you already taken to resolve the situation?

What will happen if assistance is not received?

Section 9

Housing & Utilities

Housing Status

Are you currently facing eviction?

Yes No

Have you received a utility disconnection notice?

Yes No

Are any utilities currently disconnected?

Yes No

Number of People Living in Household

Section 10

Employment & Education

Are you currently employed?

Yes No

Employer

Position

Length of Employment

Highest Level of Education Completed

Services You Are Interested In

Job Training Resume Assistance Career Counseling GED Assistance Financial Literacy Entrepreneurship Support

Section 11

Transportation

Do you have reliable transportation?

Yes No

Do you own a vehicle?

Yes No

Is transportation preventing employment, school attendance, or appointments?

Yes No

If yes, explain

Section 12

Health & Wellness

Current Physical Health

Chronic Medical Conditions

Are you currently taking medication?

Yes No

Are you currently experiencing overwhelming stress?

Yes No

Do you feel safe where you live?

Yes No

Would you like emotional or spiritual support?

Yes No

Section 13

Spiritual & Community Support

Do you currently attend a church?

Yes No

Church Name

Areas of Interest

Prayer Support Spiritual Counseling Mentoring Life Skills Coaching Financial Wellness Coaching

Sections 14 & 15

Other Assistance & Documentation

Are you currently receiving assistance from any other organization?

Yes No

Organization

Type of Assistance

Contact Information

Section 16

Client Certification & Acknowledgment

I certify that the information provided is true and accurate to the best of my knowledge. I understand:

Submission of this form does not guarantee assistance.
HHMI may verify information provided.
False information may disqualify me from assistance.
Assistance may be temporary in nature.
Referrals, coaching, mentoring, or follow-up services may be recommended.
HHMI reserves the right to determine eligibility based on available resources and ministry guidelines.

Client Signature (type your full name)

Date

Client Care & StabilizationIntake Form

Confidentiality Statement

Eligibility & Residency

Personal Information

Contact Information

Household Composition

Children & Support Systems

Household Income

Monthly Household Expenses

Current Crisis Information

Housing & Utilities

Employment & Education

Transportation

Health & Wellness

Spiritual & Community Support

Other Assistance & Documentation

Client Certification & Acknowledgment

Thank you for trusting us with your story.

Client Care & Stabilization
Intake Form