SVDP at St. Monica Intake Form

Select the zip code where you live:*

Please call 678-892-6163 to be connected to a SVdP in your area.

Client Type*

New Client

Repeat Client

Date and Location of Last Visit*

Information

Name*

First Middle Last

Social Security Number

Last 5 digits only

Marital Status

Date of Birth*

mm/dd/yyyy

Email Address*

Email Address

Gender*

Living Situation

Homeless

Room/Boarding House

Hotel/Motel/Extended Stay/Shelter

Live in Car

Staying With Friend/Family/Other

Rent Apartment/Lot/Space

Rent Home

Own Home

Address*

Street Address Address Line 2 City State ZIP Code

Hotel/Motel/Extended Stay/Shelter Information

Hotel/Motel/Extended Stay Name Address City State ZIP Code

Apartment Complex/Mobile Home Park Name

If applicable

How Long At This Address?

Primary Phone Number*

Are you currently employed?*

Yes

How long have you been employed?

Registered Parishioner at St. Monica Catholic Church?*

Yes

Household Members

First Name

Last Name

Date of Birth

Gender

Relationship

Have you or any member of your household received aid from SVdP in the past?

Aid Requested (select all that apply):

Describe the amount of aid requested for each category you selected (e.g. $215 for overdue Georgia Power bill, including fees):

Provide preferred time for a call back:

Our caller ID may display as Restricted, Unknown Caller, No Caller ID, or SVDP Helpline

Daytime

Evening

Anytime

Authorization for Release of Confidential Information

In consideration of the services to be undertaken or rendered on my behalf by the Society of St. Vincent de Paul, its members, agents or affiliated organizations (hereinafter referred to as “SVdP”), I, the undersigned, hereby authorize SVdP to receive, from any and all sources, and to release to any person or organization, any confidential information regarding me which may be necessary or useful to SVdP in relation to the services to be rendered. I hereby release SVdP from all liability in any way related to the receipt and/or release of said confidential information. I further understand that the release of this information does not guarantee that assistance will be provided, but that without such information my case cannot be presented to the Conference/Council for consideration.

Please sign below*