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Personal Information




Please enter you information below. If you need help or have questions filling out any forms, please contact us. If some of the questions or forms do not apply to you, you can skip the question or form.

















Contact Information










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Tell Us About Yourself



Monthly Income Source and Amount

Dollar Amount
Employment
Child Support
Social Security
Social Security Disability
KTAP
SNAP
Other (unemployment, retirement, etc)


Household Information



Information About Children
First Name Last Name Date of Birth Gender Race Special Needs Gender/Race not listed  Insurance Provider
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7
Child 8
Child 9
Child 10
Other Adults in Household
First Name Last Name Date of Birth Gender Race Special Needs Gender/Race not listed Insurance Provider Relationship
Current Partner or Spouse
Other Adult 1
Other Adult 2
Other Adult 3
Other Adult 4
Other Adult 5
Program Questions






Pregnancy Questions




What other organizations are you working with currently?

Do you have a case manager? If so, please provide their name and contact information.


Emergency contact name and phone number


CONSENT TO RECEIVE SERVICES

The Nest – Center for Women, Children & Families recognizes the importance of mutual respect, safety, and trust in our relationship with the people we serve. We are a safe, inclusive environment open Monday through Friday from 9:00 am to 5:00 pm. Service hours may vary among our four programs: Family Assistance Program, Child Care Program, Intimate Partner Violence Program, and Parenting Program.


The Nest Confidentiality Policy

The Nest maintains a standard of strict confidentiality regarding information pertaining to the clients we serve. Demographic information regarding clients served is used for reporting to our funders and for research purposes. No identifying information will be shared outside of The Nest without your signed permission EXCEPT when state law requires reporting:

  • To protect you or identified others from clear and immediate danger, including threats of suicide, homicide, and severe violence

  • When there is reasonable cause to believe that a child or vulnerable adult is being abused, neglected, or is a victim of human trafficking

  • When we receive a court-order or subpoena to release your information or records

Rights of Person Served

  1. To receive services in a safe and healthy environment regardless of race, ethnicity, religion, national origin, gender identity, age, disability, or sexual orientation.

  2. To have their information kept confidential.

  3. To provide feedback and evaluate the services received.

  4. To be treated with respect, dignity, fairness, and cultural sensitivity.

  5. To notify the Director of the Program and/or the Executive Director of any conflicts that you encountered while receiving services.

Responsibilities of Person Served

  1. To treat The Nest staff and others receiving services in a safe and respectful manner.

  2. To respect the confidentiality of others receiving services.

  3. To honor The Nest service environment in a way that is not disruptive to others. Any threats of violence or abusive behavior on The Nest premises will result in that person’s termination from all Nest services. Weapons are not allowed on The Nest property.

  4. To inform the staff of any protective orders that I have in place against others or others have against me. Those with a protective order against them will be reviewed by The Nest personnel for the appropriate services, and may be subject to restricted access.

  5. To inform the staff of pending or substantiated charges of child sexual misconduct or child fatality. The Nest has the right to delay or deny services until these issues have been resolved.

By signing this agreement on the next page, I acknowledge I understand and can follow the guidelines listed above:

Contact Information