Financial Assistance Assessment Form

Emergency Services: Financial Assistance Assessment

Name *

Safe Phone Number (for CVRCC to call): *

Safe Email Address (for CVRCC to email): *

What crime happened to you? *

What was the date of the Crime?

Year

Month

Day

Did you file a Police Report? *

Yes

Did the crime cause you to miss a payment on your utilities/rent? *

Yes

What is your monthly income?

What is the source of the income? *

Employment

SSI

None

Other

Specify other source of income *

Have you used any of the following services within the past 2 years? *

CVRCC

MIFA

CSA

NONE

CVRCC Service Date *

Year

Month

Day

MIFA Service Date *

Year

Month

Day

CSA Service Date *

Year

Month

Day

How has this crime caused a financial hardship? *

Do you have minor children in the home? *

Yes

How many Children? *

Children Details (Age, Gender) *

Do you have a mental health or physical disability diagnosis? *

Yes

Will you be able to make next month’s payment on both utilities and rent? *

Yes

Have you been affected by COVID-19 physically, financially or emotionally? If so please explain

Are there other issues you would like to discuss? *

Yes

THE FOLLOWING QUESTIONS ARE FOR Intimate Partner Domestic Violence Clients ONLY:

Did your partner contribute to the household bills?

Yes

Has your partner left the house?

Yes

Will your partner be returning to the home?

Yes

Will you be able to pay next month’s bills?

Yes

Did you or do you plan to file an order of protection?

Yes

Were you or your partner arrested for this crime?

Yes, I was arrested

No, I was not arrested

Yes, my partner was arrested.

No, my partner was not arrested.

Check all that apply (may be more than one):

By typing your name below, you are certifying that the above facts are true to the best of your knowledge and belief.

Client Full Name *

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Translator

Emergency Services: Financial Assistance Assessment

THE FOLLOWING QUESTIONS ARE FOR Intimate Partner Domestic Violence Clients ONLY:

By typing your name below, you are certifying that the above facts are true to the best of your knowledge and belief.