MDC Service Intake Form
Please fill out the form to access MDC services. It may take about 10-15 minutes to complete.
For any questions or assistance, please contact (253) 284-9096 or
info@mdc-hope.org
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Please select your language.
Getting Started:
By filling out this form, you give permission to MDC to use your personal information for referrals to other
internal
programs and your anonymized information to our federal funding sources.
MDC will
not
share your personal information to any other entities.
Provide your email address here.
You must have access to this email address to confirm your application.
Participant Info
First Name
Last Name
What is your Date of Birth?
You can use the calendar or type using MM/DD/YYYY.
Age
Street Address
Unit / Apartment #
Please use the placeholder address' format.
City
ZIP Code
State
Cell Number
I consent to receiving text messages from MDC
Yes
No
Alternate Phone
What is your gender identity?
Male
Female
Non-binary
Genderqueer
Other
Prefer not to say
What is your ethnicity?
Hispanic or Latino
Non-Hispanic or Latino
What is your race?
American Indian/Alaskan Native
Asian
Black/African American
Hawaiian/Pacific Islander
White/Caucasian
Multi-racial
Unknown
Prefer not to say
Other
Please specify:
What is your Citizenship status?
U.S. Citizen
Permanent Resident
Visa Holder or Other
Are you an immigrant, refugee, or an asylum seeker?
Yes
No
Do you have difficulty reading, writing, speaking, or understanding English?
No
Yes
Sometimes / Partially
What is your preferred language, if not English?
Please select...
English
Afrikanns
Albanian
Amharic
Arabic
Armenian
Basque
Bosnian
Bengali
Bulgarian
Catalan
Cambodian
Cantonese
Croatian
Czech
Danish
Dutch
Estonian
Farsi
Fiji
Finnish
French
Georgian
German
Greek
Gujarati
Hebrew
Hindi
Hungarian
Icelandic
Indonesian
Irish
Italian
Japanese
Javanese
Korean
Latvian
Lithuanian
Macedonian
Malay
Malayalam
Maltese
Mandarin
Maori
Marathi
Mongolian
Nepali
Norwegian
Persian
Polish
Portuguese
Punjabi
Quechua
Romanian
Russian
Samoan
Serbian
Slovak
Slovenian
Spanish
Swahili
Swedish
Tagalog
Tamil
Tatar
Telugu
Thai
Tibetan
Tigrinya
Tonga
Turkish
Ukranian
Urdu
Uzbek
Vietnamese
Welsh
Xhosa
Other
Please specify:
What is your
highest level
of education received?
Current High School Student
Some High School ("drop-out")
Enrolled in GED/ABE program
High School Graduate / GED Recipient
Some College ("drop-out")
Current College Student
Two-year Associate Degree
Bachelor's Degree
Other
Please specify:
Did either of your parents receive a 4-year (Bachelor's) degree?
Yes
No
If unsure, please check "No."
Household Info
Marital Status:
Single
Married
Divorced
Widowed
Legally Separated
Domestic Partnership
What is your household size?
Household size includes you, your spouse, and any children, dependents, or relatives that lived with you last year.*
Please estimate your
household's
monthly
income
This includes unemployment, SSA, etc.
Please select all state or federal benefits that you receive:
SNAP
WIC
TANF
SSI / SSA
Medicare
Medicaid
Other
Please specify:
Do you have a military connection?
Veteran
Active Duty
Spouse of Active Duty
Dependent of Active Duty
None
Have you experienced homelessness in the past year?
No
Yes
Have you ever been in foster care or a ward of the state?
No
Yes
Have you ever been determined to be an unaccompanied, self-supported, or at-risk homeless youth?
No
Yes
Service Need Info
Please select any other MDC service(s) that you are interested in:
Child Care Food Program
Computer Training
Education
Employment
Energy Assistance
Home Weatherization
Housing and Support Services
Individual and Group Counseling
Medication Management
Mental Health Services
Recovery Services
Withdrawal Management
Other
Please specify:
Do you have any disabilities?
Physical
Learning
Are you deaf or hard of hearing?
Yes
No
Will you need accommodations?
Yes
No
Not Sure
Are you or have you ever been incarcerated?
Yes
No
Do you have reliable access to the internet?
No
Yes
Through a library, phone plan, or home access.
Are you interested in resources for internet access?
No
Yes
Optional Survey
How did you hear about this program?
Family or Friend
MDC Website
Flyer Or Door Hanger
Referral
Other
Please specify the person or group that referred you
If other, how did you hear about this program?
How was your experience with this online application?
It was quick and easy
It was easy, but lengthy
The questions were confusing
The layout was overwhelming
I had difficulty gathering the required documents
I had difficulty finding this form
I had difficulty getting access to a computer or the internet
Select all that apply
Are there any other services that you are looking for? Please explain.
Please enter any final comments or concerns about your experience here.
Thank you for taking the time to fill out this form. Please click "Submit my Intake Form" to complete your submission.
Need help? Contact us