Client Referral & Screening Form

1. Does your household need help with food?

2. Does your household receive WIC or Food Stamps (SNAP)?

3. Does anyone in the household currently work?

4. Does anyone in the household have dietary restrictions or food allergies?

5. Does anyone in the household need help with transportation?

6. Is your household behind on paying rent?

7. Does your household receive Section 8 housing assistance?

8. Has your household's electricity been shut off or received a shut-off notice?

Client Status