FCS PROGRAM

Today's Date

FCS Service Requested FCS Service Requested Employment Housing

Immediate Crisis Needed

First Name

Last Name

Date Of Birth

Phone

Email

Choose One Choose One Housed Unhoused

Mailing Address

Type of Income Type of Income SSI/SSDI Employment Part Time / Full Time Unemployed TANF / SNAP

Rental History Rental History Yes No

Eviction History Eviction History Yes No

Transportation Transportation Vehicle Public Transportation

Criminal Record Criminal Record Yes No

If "Yes", when was the conviction?

Housing Program

Have you ever received treatment for addiction or mental health Have you ever received treatment for addiction or mental health Yes No

Treatment Organization

Would you like information on receiving a MH / SUD assessment? * Would you like information on receiving a MH / SUD assessment? * Yes No

Do you have any disability requiring a caregiver? Do you have any disability requiring a caregiver? Yes No

Are you enrolled in Washington State Medicaid? Are you enrolled in Washington State Medicaid? Yes No

Provider One Number

Verbal Consent to look up Provider One Number Verbal Consent to look up Provider One Number Approved Verbal Consent

Applicant

Agency Staff