Citadel Client Program Interest Form

Thank you for your interest in the receiving services from Citadel Community Development (CCD). We have several programs that will assist you in achieving self-sufficiency. Please complete the form below so that we are able to begin your pre-intake process. Once youhave comnpleted this form, youmay be directed to complete another form based on your answers. It is important that you complete each form as honestly as possible because this will help us determine what programs you may qualify for. dont worry if you don't understand a question, a Citadel Team member will review your answers with you during your intake.

Once your application has been received, you will be contacted by a CCD staff member to provide you with the next steps. Again, thank you for your interest in the receiving services from Citadel Community Development. Thank you for the opportunity to serve you.

Form Submission Date

First Name *

Last Name *

Birthdate * +

SSN

Gender

Age *

Race

Marital Status

Referral Source *

Street Address

City

State (Please use 2 Letter Abbreviation)

Zip Code *

Home Phone *

Mobile Phone

Email *

Emergency Contact Name

Emergency Contact Phone

Ok to Leave Message? *

Household Type

Relation to Head of Household

Number in Household

Prior CCDC Client *

Are you currently on Probation/Parole *

Special Needs/Concerns

Services Needed *

Parole/Probation Officer's Name *

Total Monthly Income (All Sources)

Current Rent Amount

Income Source(s)

Non-Cash Benefit Source(s)

Emergency Housing	Transitional Housing	Rental Housing
First-Time Homeownership	Foreclosure Counseling	Job Readiness (Job Club)
Resume Development	Career Planning	Employment Search/Placement
Internship	GED/HS Diploma	Vocational/Trade School
College/University	Apprenticeship Program	Scholarship/Financial Aid Assistance
Basic Living Skills	Basic Financial Literacy	Credit Building and Restoration
Basic Transportation Skills	Other

Child Support	Earned Income	General Assistance
Pension	Private Disability Insurance	Social Security Retirement
Social Security Disability	Supplemental Social Security	TANF/Cash-Aid
Unemployment Insurance	Veteran's Disability Insurance	Veteran's Pension
Worker's Compensation	Other Source

Medicaid	Medicare	Cal-Fresh/Food Stamps
Section 8/Other Ongoing Rental Subsidy	WIC	Child Care Subsidy
Transportation Subsidy	Temporary Rental Assistance	VA Medical Services
Other Source