COUNSELOR/LEGAL PROVIDER:
1. DATE:
2. CLIENTS SS#:
3. CLIENTS NAME (First, MI, Last:
4. CLIENTS GENDER (M,F):
5. ADDRESS:
6. HOME PHONE:
7. CITY, TX, ZIP, COUNTY:
8. COUNTY:
9. PHYSICIAN: N/A
10. PHONE: N/A
11. RACE: (Check one):
BLACK
WHITE
NATIVE AMERICAN
HISPANIC
ASIAN
OTHER
12. MARITAL STATUS: (Check one):
MARRIED
WIDOWED
DIVORCED
SEPARATED
NEVER MARRIED
NO INFORMATION
13. TOTAL in HOUSEHOLD: (Include Client):
14. INCOME: (Check one):
LOW
MEDIUM
HIGH
SSI
15. REFERRAL PERSON:
16. REFERRAL PHONE#:
17. 60+ CLIENT?
18. DATE of BIRTH
19. TDHS CBA CLIENT? N/A
20. DHS WAITING LIST? N/A
21. HAS GUARDIANSHIP? N/A
22. REPRESENTATIVE PAYEE? N/A
ISSUE: (Consult Client Profile of Need Catagories) CAN BE MORE THAN ONE ISSUE
TYPE of SERVICE NEEDED (Check all that Apply):
ADVICE/COUNSELING
DOCUMENT PREPARATION
REPRESENTATION
OTHER (Describe Below)
CLIENT WAS REFERRED TO:
LEGAL PROVIDER
SSA
LEGAL HOTLINE
DEPARTMENT of INSURANCE
DHS
OTHER (Describe Below)
NOTES ABOUT REFERRAL(S):
MONETARY IMPACT: (Comlete only if feasable, known, and accomplished with your assistance)
a. ONE TIME AWARD:$
b. RECURRING BENEFITS:$
TOTAL FOR YEAR$
| Clicking the "SEND IT" button will email this form (if allowed by browser) to a Benefits
Counselor. additionally a copy will be saved for you. |
| Select Either of These Two Buttons
|