Client Contact Form

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SHINE CLIENT CONTACT FORM
*Client First Name:
Representative First Name:
*Client Last Name:
Representative Last Name:
Client Phone Number (
)
*ZIP Code of Client Residence:
County of Client Residence:
Address:
*Counselor:
*Agency:
*ZIP Code of Counselor Location:
*County of Counselor Location:
*Date of Contact:
*First vs Continuing Contact:
*How Did Client Learn About SHINE (Select One Only):
First Contact for Issue
Previous Contact
Continuing Contact for Issue
CMS/Medicare
Presentations
Mailings
Another Agency
Friend/Relative
Media
State Website
*Method of Contact:
*Client Age Group:
*Client Gender:
Phone Call
64 or Younger
Female
Face to Face at Counseling Location or Event Site
65-74
Male
Face to Face at Client’s Home or Facility
75-84
Email
85 or older
Postal Mail or Fax
*Client Race-Ethnicity:
*Client Primary Language Other Than English
Hispanic, Latino, or Spanish Origin
Primary Language Other than English
White, Non-Hispanic
English is Client’s Primary Language
Black, African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Asian
Other Pacific Islander
Some Other Race-Ethnicity
*Client Monthly Income:
*Client Assets:
Below 150% FPL
Below LIS Asset Limits
At or Above 150% FPL
Above LIS Asset Limits
*Receiving or Applying for Social Security Disability:
*Dual Eligible with Mental Illness/Mental Disability:
Yes
Yes
No
No
*
required by CMS – must be filled out
September 2015

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