Form Dhs 1277 - Service Questionnaire Page 2
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10Personal information
Are you a US citizen?
Yes
No
If no, do you have a work permit?
Yes
No
Contacts:
Name:
Relationship:
Phone number:
Name:
Relationship:
Phone number:
Counselor notes:
Your living situation:
Community residential/group home
Halfway house (transition living)
Homeless/shelter
Live with parents
Private residence (independent)
Marital status:
Never
Married
Divorced
Separated
Widowed
Domestic partner
Members living with you (check all that apply):
Self only
Self/partner and/or children
Parents
Other:
Who referred you to this agency?
Income
Monthly average income:
Amount:
How do you currently support yourself financially?
Social Security Income (SSI):
Social Security Disability Income (SSDI):
Temporary Assistance for Needy Families (TANF):
Supplemental Nutrition Assistance Program (SNAP):
Subtotal:
Source:
Program:
Amount:
Workers’ compensation:
Veterans:
Personal income:
Other:
Total:
Counselor notes:
Page 2 of 10
DHS 1277 (10/2016)
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Parent category: Legal