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It captures vital information including employment status, household composition, financial income levels, and existing government benefit participation. The document further identifies specific barriers to self-sufficiency, such as transportation, childcare, or education gaps, and allows applicants to select from a wide range of agency services, including housing assistance, training programs, and community referrals, to facilitate support and long-term goal attainment.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":57,"@type":76,"position":81},"https://docshare.wps.com/document/general/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/service-coordination-form-2023-intake-document/324023/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/service-coordination-form-2023-intake-document/324023.png","ImageObject",300,407,{"name":92,"@type":93},"eBook King","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-22","2026-09-21",true,{"@type":102,"interactionType":103,"userInteractionCount":52},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What personal information is required to complete this form?","Question",{"text":112,"@type":113},"Applicants must provide their name, phone number, email address, date of birth, county of residence, and the last four digits of their social security number.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What types of financial assistance records does the form request?",{"text":117,"@type":113},"The form asks for information regarding assistance received in the last 30 days, such as TANF, Medicaid, SNAP, SSI/SSDI, and unemployment compensation.",{"name":119,"@type":110,"acceptedAnswer":120},"How does UCHRA identify the specific needs of an applicant?",{"text":121,"@type":113},"The form provides a comprehensive checklist of available services, including transportation, weatherization assistance, utility bill support, job training, and opioid addiction referrals, allowing the applicant to indicate their specific requirements.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},324023,1790383871,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":56,"category_name":57,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":8,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":14},962088006270,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Service Coordination Form  \nDate:   First Name:    \nPhone Number:  \n________________________________  \nCounty of Residence: ______________________  \nLast 4 of Social:  \n_________________________  \nLast Name:   Email:    \nDate of Birth:  \n___________________________  \nWhat is your current employment status? Employed Unemployed  \nAre you interested in completing a certification or training program? Yes No  \nWhat is your household size:   What is your gross household income:    \nWhat are the names and ages of all members living in your household:    \n____________________________________________________________________________________________________  \nFinancial Assistance – Please check all forms of assistance that members of your household have received in the last 30 days. TANF Medicaid Unemployment Compensation  \nSSI/SSDI Subsidized Housing Other:    \nSNAP (Food Stamps) Free or Reduced Lunch  \nCurrent Barriers – Please check/add all barriers that are keeping you from meeting your self-sufficiency goals.  \nEducation Level Homelessness  \nPrevious Offender  \nLack of Transportation  \nLack of Childcare  \nLack of Job Skills  \nEducation Level – Please check your highest level of education achieved.  \nNone Some College  \nHS Diploma Associates Degree  \nUCHRA Services – What services are you and/or your household in need of?  \nTransportation Commodities Family Engagement Driver’s Education Utility Bill Assistance Empower UC  \nEmployment and Training Community Referrals Weatherization Assistance Opioid Addiction Services/ Referral Information on CASA Homemaker Aid Assistance  \nOther:    \n____________________________  \n____________________________  \n___________________________  \nBachelor’s Degree Master’s Degree  \nOther:    \nOther:    \nOther:    \nOther:    \nForm Updated: 01/2023","cbCaisKhlfQBRdzc","https://ap.wps.com/l/cbCaisKhlfQBRdzc","pdf",237099,"English","# Personal Information\n## Employment and Household Details\n# Financial Status and Assistance\n## Household Income and Benefits\n# Barriers to Self-Sufficiency\n## Education and Support Needs\n# UCHRA Services Selection","[{\"question\":\"What personal information is required to complete this form?\",\"answer\":\"Applicants must provide their name, phone number, email address, date of birth, county of residence, and the last four digits of their social security number.\"},{\"question\":\"What types of financial assistance records does the form request?\",\"answer\":\"The form asks for information regarding assistance received in the last 30 days, such as TANF, Medicaid, SNAP, SSI/SSDI, and unemployment compensation.\"},{\"question\":\"How does UCHRA identify the specific needs of an applicant?\",\"answer\":\"The form provides a comprehensive checklist of available services, including transportation, weatherization assistance, utility bill support, job training, and opioid addiction referrals, allowing the applicant to indicate their specific requirements.\"}]","Service Coordination Form - 2023 - Intake Document | PDF",1789966818]