Decluttering/Yard Cleanup: Request for Service

Eligibility:

Lives withing King County
Income at or below 80% AMI: $66,750 for one person annually, $76,250 for two people annually
55 and older

Directions: Please complete as much of this form as possible. All referral information is processed using HIPAA-compliant platforms.

Client Information

First Name

Last Name

Street Address

City

Zipcode

Phone Number

Date of Birth

Income Amount (do not include $ sign)

Income Amount is:

MonthlyAnnual

Household size:

One personTwo people or more

Gender

FemaleMaleTransgender/OtherUnknownPrefer not to say

Gender Self-Describe (Other)

Veteran

YesNo

Related to a veteran?

YesNo

Race/Ethnicity (check any that apply)

American Indian or Alaska NativeAsian, Asian-AmericanBlack, African, African-AmericanHawaiian Native or Pacific IslanderLatino/HispanicWhite, CaucasianOtherUnknownPrefer not to say

Race Self-Describe (Other)

Sexual Orientation

HeterosexualGayBisexualLesbianQuestioningOtherPrefer not to say

Referral Info

Referral Source Name

Referral Source Organization

Referral Source Phone

Referral Source Email

Able to assist client with coordination of project if client has challenges with memory, hearing loss or other?

YesNo

Project Info

Project type

DeclutteringYard Clean Up

Type of Housing

Owns homeLives in home owned by family memberRenter

Is the client willing to have their home/apartment decluttered?

YesNo

Requested service

Briefly describe what needs to be done

Project Scope (check all that apply)

Improve AccessibilityReduce Risk of FallsPrevent EvictionImprove living space usabilityReduce fire hazard.

How else will this improve the health and safety of the older adult?

Contact Information