Intake Form

Community Health Center of Buffalo

Office For Victims of Crime and Office of Victim Services
Client Intake Form

Intake Form

WHAT SERVICES ARE YOU INTERESTED IN APPLYING FOR?*


COMPLETING THIS APPLCIATION

 

We need information about you and anyone living in your home. Providing the size of your household and income helps us determine if you are eligible for services. Our funders require the rest of the information. Please note some services require us to collect additional information and documentation.

 

APPLICANT INFORMATION

Victim Classification

Narrative

Work Status

Marital Status

Special Classification


HOUSEHOLD INFORMATION

Special Classification

Household Status

Housing Status

Race


Gender

Health Insurance


HOUSEHOLD NON-CASH BENEFITS

 

Check any benefit that you or your household currently receives:


HOUSEHOLD INCOME

 

List the monthly amount of any income that you or your household currently receives. Please use gross income. Gross income is what you earn before taxes and deductions.

Source of Income

 

Applicant:

Additional Household Member:

The information I have provided is true and correct. If needed I will provide documentation to verify my residency, the size of my household and income. I understand completion of this form does not guarantee that I will receive assistance from the Community Health Center of Buffalo.