Intake Module

Step 1 of 10

Case Manager Disclosure & Acknowledgment

I acknowledge that I am not an employee of CARS NETWORK but only a volunteer and have completed the CARS NETWORK volunteer application, attended the CARS NETWORK orientation, and completed the CARS NETWORK training. I further commit to keeping client information confidential and verify and vet the applicant according to CARS NETWORK training and policy.*

I agree to the above.

Client Personal Information

ALL FIELDS MUST BE COMPLETED TO CONTINUE TO THE FOLLOWING STEPS

Full Name

Address

Phone number (789-456-1230)

Email address

Date of birth

Marital status

How many children/dependents live in your household?

Please enter a number less than or equal to 12.

Are you currently attending school or enrolled in any educational program?

Yes

What is your highest level of education completed?

Where were you born?

Ex-spouse (Mother/Father of kids) information:

Full Name

Location (i.e., Houston, Texas; France, Mexico)

Contact information (if known)

Is he involved in the children’s lives?

Yes

Names of your children/dependent

Dates of birth of your children/dependent

Intake Module

Case Manager Disclosure & Acknowledgment

Client Personal Information

Church/Organization Affiliation

Employment & Income

Vehicle Information

Financial Readiness

Personal Circumstances & Need

Legal & Safety Status

Documents/Photo Upload

Consent to share client story

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