CONNECT Intake - v2

CONNECT Partners
4 Gerrish Ave, Chelsea / (617) 889.1375 / www.connectnow.org

WELCOME TO THE CONNECT ONLINE INTAKE FORM

Several of the questions on our intake form are personal in nature. This information allows us to determine how we can best help you.
  • CONNECT is a partnership of five organizations that offer you services.
  • The partners use a single database to collect and share information about clients.
  • CONNECT has and follows an Information Security policy to protect your information.
  • We give our supporters information about CONNECT activities and our clients’ progress.  This information never contains your name without your permission.

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Please enter 0, if no one in your household is under 18. We ask this question because some of our services are only available to families with children.


24. CONNECT offers many services: How interested are you in achieving each of the following?
Not Currently Interested Somewhat Interested Interested Very Interested

How much do you currently earn from your job(s), before taxes?
$



You have indicated that you are concerned about your housing situation or are homeless. By providing us with the following information, we can assess whether you might be eligible for monetary assistance called RAFT (Residential Assistance for Families in Transition). You can always choose to not answer a question if you are uncomfortable. 




Please enter the child's age in years. Enter 0 for children who have not had their 1st birthday.















37. Does your family currently use any of the following? 
Yes No Don't Know


40. Consent to pull credit reports

I, a participant in the CONNECT Program, authorize The Neighborhood Developers, Inc. (TND) to request a Factual Data consolidated tri-merge credit report.  This credit report will be provided to me at no cost on request.  My electronic signature below authorizes the credit reporting agencies to obtain information regarding my outstanding credit accounts (mortgages, auto loans, personal loans, charge cards, credit unions, etc.) no more than twice per year for a maximum of 5 years, or completion of the CONNECT Financial Coaching Program if applicable.  Authorization is further granted to the reporting agencies to use a photo static reproduction of this authorization if necessary to obtain any information regarding the above mentioned. 

 

I understand that this credit report can be made available to me for financial counseling purposes and to aid in my financial well-being.  Additionally, I release my credit score to TND and CONNECT for data collection and evaluative purposes. I understand that it will be used only in the aggregate without personal identifiers and will never be released to a third party without my consent.  Any reproduction of this credit report authorization and release made by reasonable means (e.g. photocopy or facsimile) is considered an original.


ATTENTION: After you complete the CONNECT intake form, you will see an error message. IGNORE THIS ERROR MESSAGE.  Please do not complete the intake form a second time. Instead, contact the receptionist (in person or at 617-889-1375, ext. 0) to ensure that the correct CONNECT service provider has been notified of your interest in their assistance.  We are working to fix this problem as soon as possible.  Thank you for your patience.

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OK, you will not be matched with any services.  If you want to learn about any of our services, please talk to the receptionist at the front desk or call (617) 889-1375.

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