FWB Jotform Master (Helen)

Welcome to Family Well-Being

We want to help you as quickly as possible. Please fill out all the questions in the next page and we'll get you help right away.

Name*

First NameLast Name
Phone Number *
Please enter a valid phone number.
Primary Email / Correo Electronico
example@example.com
Other Phone Number
Please enter if client has international number
DO NOT USE Retired 11/6/2023 Other Phone Number

Country CodeArea CodePhone Number
DO NOT USE Name

First NameLast Name
DO NOT USE Birth Date / Fecha de Nacimiento 1

Month / MesDay /DiaYear / Año
Phone Number
Please enter a valid phone number.
How did you hear about us? / Como escucho del LAA? *

Word of Mouth (Family & friends)InstagramFaceboookLinkedInGoogle SearchLAA WebsiteTV / RadioEmailExternal referralPrint advertisingSchool, College or UniversityGovernment AgencyLAA Internal Referral
How would you like to receive service? Cómo querias recibir nuestro servicios?

in person / en personaby phone / por telefono
Why can't you come in person? / Porque no puedes venir a nuestra oficina?

Medical reason / Razón medicalLack of transportation / No tengo transporteWork / TrabajoLack of time / No tengo tiempoNeeds childcare / Necesita cuidado de niñosLive far away / Vive LejosOther
Are you currently looking for a job? / Esta buscando Empleo?

Yes / SiNo / No
Do you have work authorization in the U.S.? / Tiene Permiso de trabajo en EE.UU?

Yes / SiNo / NoWaiting for approval / Esperando su approbacionDecline to answer / Prefiero no responder
What service are you requesting today?*

Public Benefits (SNAP, MEDICAID, OTHER) / EstampillasFinancial Assistance (Rental, Mortgage, Utility) / Ayuda con renta o utilidadesEmergency Food Assistance (in person Dekalb and Gwinnett) / Despensa de ComidaVictim of Violence (Domestic, Stalking, Sexual) / Victimas de violencia (domestica, acecho, sexual)Newcomer Orientation / Orientacion de recien llegadosAging and Disability / Personas mayores y personas con descapacidadesSenior Club / Club de la Tercera EdadHEPI - Juntos por una vida saludableAssessment CenterExternal Referral / Referente externoInternal Referral / Referente internoKaiser Permanente Mobile Unit Sign-UpClothing Assistance
County*
Important message for clients interested in the Dekalb ICC program

This program is only available for residents of DeKalb County. If you do not live in DeKalb, unfortunately, we cannot process your application for this program. We encourage you to check for other programs in your area that may meet your needs. Thank you for your understanding.

Mensaje Importante para Clientes Interesados en el Programa ICC de DeKalb

Este programa está disponible únicamente para residentes del condado de DeKalb. Si no resides en DeKalb, lamentablemente no podemos procesar tu solicitud para este programa. Te invitamos a verificar si hay otros programas disponibles en tu área que puedan satisfacer tus necesidades. Gracias por tu comprensión.
Are you looking for other services inside the LAA?*

HEPI - Juntos por una vida saludableImmigration ServicesEnglish classes (online or in person)EmploymentWomen's Entrepreneurship Program (Avanzando Juntas)Digital/Computer ClassesProfessional training (Path to Pro, Unidos en Finance, LatinX in Tech)TranslationsYouth mentorship (Sequoyah MS, Cross Keys HS, Lilburn MS, Meadow Creek HS)Senior college advising (12th grade and up)Youth summer programI am not looking for other services from the LAA at this moment.Spanish ClassesOther
Assessment Center - Screening Form
Birth Date / Fecha de Nacimiento*

MonthDayYear
Date
Nationality
How many members will receive clothing assistance?*
Include person who registered.
Age (Hidden in form)

Type of appointment

EmergencyThursday Appointment
Date of Emergency Food Assistance - WALK-IN ONLY*

MonthDayYear
Date
We are currently at full capacity and not taking new clients. Please refer out the client to one of our partners.
DeKalb Appointment
Gwinnett Appointment
Pounds of Food
Pounds
Food Dispense Completed?

YesNo
Ethnicity*

Hispanic or LatinNon-Hispanic WhiteNon-Hispanic Black
Gender / Género*

Female / MujerMale / HombreNonbinaryPrefer not to answer / Prefiero no contestarTransgenderUnknownOther
Race*

MultiracialCaucasian (White)African American (Black)AsianAmerican IndianAlaska NativeNative Hawaiian and Other Pacific IslanderUnknownOther
Disabled*

Yes (can be cognitive, motor, sensory, or mental illness)NoDeaf/Hard of HearingUnknownPrefer not to answer
Martial Status*

SingleMarriedDivorcedSeparatedDomestic PartnerWidow
Are you a veteran?*

YesNoPrefer not to answer
Address / Dirección - Financial Assitance*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Zip Code*
How many members are in your household?*
Count every single person that lives in the house
Number of dependents*
Number of children under 18 / Cuantos hijos menores de 18 tiene en casa*
Number of senior 60+ / Cuantos personas mayores (edad 60 o mas mayor) tiene en casa?*
List here ages and gender of dependents in your household*
Client ID (not case Number) / Número de indentificación del cliente
Can be found on EBT card and DFCS notices. If client is new, please write "new client." If client does not know client ID, please write "unknown."
DO NOT USE Client ID
Service Requested

Food Stamp RenewalFood Stamps ApplicationAdvocacySend DocsWICOther
Please ask the client if they would like a combined application and select the option(s) below.

CAPSTANFMedicaid/PCK
Please select the service client was calling about:

CAPSTANFMedicaid/PCK
Other
REPORT CHANGES - Inform recent client (with EasyTrak profile) that they will need to be prepared with proof/verification of change they are trying to make and that it may take time for DFCS to realize this change. Encourage to also call DFCS to make the change or to do it in a renewal. Client MUST have client ID and proof of verification of change handy to report changes.
CHECK CASE - Service Request for existing LAA EasyTrak clients for the purpose of checking status of benefits, notices, checking renewal dates, etc.
ADVOCACY - Inform client that you can add to the list and that the staff will determine if an advocacy is needed or if they just simply need to wait or take another route. Client must have been served by LAA staff in the past four (4) weeks. LAA reserves right to accept or decline request for advocacy.
SEND DOCS Intake staff, please ask/explore if a client we recently helped. Collect info ONLY if a client was served in the last four (4) weeks/refer back to DFCS or other agency if we did not do the app/renewal. Disclaimer - adding client for this service does not guarantee documents will be submitted before due date.

Make sure you collect:
- Client ID
- DOB
- Document Due Date
- LAA Staff who assisted
- If PAST DUE DO NOT TAKE CLIENT - REFER OUT.
ENGLISH PROMPT

"Thank you for reaching out to the LAA for assistance with your public benefits. If you need further assistance with your document submission you can contact your caseworker (contact info found in notice of decision letter) you can also contact your local DFCS at 1877-423-4746 or via www.Gateway.ga.gov If you need to find your local DFCS office hours/days of operations please click on this link https://dfcs.georgia.gov/locations"

SPANISH PROMPT

"Gracias por contactar La Asociación LatinoAmericana para asistencia de beneficios públicos. Si necesita asistencia para mandar sus documentos, usted puede llamar a su trabajador de caso de DFCS (puede encontrar la información del trabajador de caso en la carta de benficios), usted tambien puede contactar a su DFCS local al 1877-423-4746 o via www.Gateway.ga.gov Si usted necesita localizar su oficina de DFCS y los horario/dias de operacion, por favor siga el enlace https://dfcs.georgia.gov/locations"
DISCLAIMER for other services: Intaker, please read the following to client OR send via text.

Gracias por contactar a La Asociación Latinoamericana (LAA). Actualmente, no estamos aceptando casos de Beneficios Publicos ya que hemos alcanzado nuestra capacidad por el momento.
Para asistencia, puede contactar a DFCS al 1-877-423-4746 o encontrar su oficina y horarios aquí: https://dfcs.georgia.gov/locations Si necesita ayuda urgente, consulte otras organizaciones aquí: https://tinyurl.com/488xdxbd. IMPORTANTE: Estas organizaciones no están afiliadas a la LAA.
Para verificar su caso en la aplicación móvil de Gateway, siga este video instructivo: https://thelaa.org/wp-content/uploads/2023/04/gateway-how-to.pdf
DISCLAIMER for other services: Intaker, please read the following to client OR send via text.

Gracias por contactar a La Asociación Latinoamericana. Actualmente, solo aceptamos solicitudes que incluyan Estampillas/EBT o WIC, ya que debemos priorizar estos casos para cumplir con los objetivos de nuestro programa.
Si necesita asistencia con una solicitud singular de Medicaid, CAPS o TANF, puede contactar a DFCS al 1-877-423-4746. Para ubicar su oficina local y horarios, visite: https://dfcs.georgia.gov/locations
Si necesita ayuda urgente, consulte otras organizaciones aquí: https://tinyurl.com/488xdxbd

IMPORTANTE: Estas organizaciones no están afiliadas a la LAA.

Para aplicar por su propia cuenta, puede usar la aplicación móvil de Gateway. Siga estas instrucciones: https://thelaa.org/wp-content/uploads/2023/04/gateway-how-to.pdf
The client has been given the courtesy message and referred to DFCS and a community partner agency.*

YesNo
Intake Notes (For internal use: receptionist, intern only)
If multiple services requested, please explain.
What is your immigration Status / Cual es su status migratorio?

US Citizen / Ciudadano AmericanoUS Resident / Residente AmericanoWork Permit / Permiso de TrabajoNo immigration status / Sin estatus migratorioDecline to answer / Prefiero no responder
Have you received financial assistance from The LAA in the past year?

YesNo
Housing status

Literally homelessPartially homelessInminent losing housingUns
Do you have a Social Security Number? / Tiene número de seguro social?

YesNo
Do you have a GA ID?

YesNo
What type of financial assistance you need? ? ¿Qué tipo de ayuda financiera usted necesita?

Utilities / UtilidadesMortgage / HipotecaRent / Renta / Aquiler
Important message!

DeKalb ICCI does not pay mortgages. You may submit your information; however, we are unable to process your case at this time

¡Mensaje Importante!

DeKalb ICCI no paga hipotecas. Puedes enviar tu información, pero en este momento no podremos procesar tu caso.
Which utility bill area you behind? Que factura de utilidades está atrasada?

Electricity / LuzWater / AguaGas
Have you received the following:

Eviction noticeDisconnect noticeNeither
Is the bill under your name? ¿La factura está a nombre de usted?

YesNo
How much is the total bill? ¿Cuál es el total que debe de su factura?
How much do you pay for rent each month? / ¿Cuánto paga de Renta cada mes?
When is the bill due? Cuando vence la factura?

MonthDayYear
Date
Is the lease contract under your name? ¿El contrato este a su nombre?

YesNo
Is current? ¿Esta actualizado?

YesNo
Are you under section 8? ¿Está usted bajo el programa de sección 8?

YesNo
How many bedrooms does your place of living have? ¿Cuántos cuartos tienen la casa o apartamento?
How many months behind are you?
What is the plan for the next couple of months? ¿Cuál es su plan por los próximos meses?

0/0
Are you a victim of crime within the United States? ¿Usted fue víctima de algún crimen en los Estados Unidos?

YesNo
Government/ other assistance (SNAP, TANF, Child Support, SSI, etc)? / Recibe alguna ayuda del gobierno? (estampillas, TANF, Medicaid, Manutención Infantil, SSI, etc?:

YesNo
Not in use - Which month are you requesting assistance for? / Para que mes necesita assistencia?
What month do you need help with rent? / ¿Para qué mes necesita ayuda con renta?

JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
What's the reason you're requesting financial assistance? Por que esta pidiendo assistencia financiera

Homeless / No tiene hogar/casaLost job / perdidaMedical / MedicalEviction / DesalojoCOVIDReduced hours / Falta de horas en trabajoFamily emergency / Emergencia familiarOther
Child 1 gender / Género de hijo 1

Female / MujerMale / HombreNonbinaryPrefer not to answer / Prefiero no contestarOther
Child 1 age / Edad de hijo 1
Tell us how we can help you? En que podemos ayudar? Please make sure leave a time period during the week that we can contact you. We will do our best to accommodate your schedule. Our hours of operation are Monday through Friday 9 am - 5 pm - excluding holidays. Asegúrese de dejar un período de tiempo durante la semana en el que podamos comunicarnos con usted.Tendremos esto en cuenta cuando le devolvamos la llamada. Nuestro horario de atención es de lunes a viernes de 9 am a 5 pm, excepto feriados.
Do you feel safe right now? Siente seguro en este momento? If client feels in danger please ask them to immediately call 911.*

YesNo
Are you in need of shelter? Necesita alojamiento/refugio? - Remind the client that we are only open Monday - Friday from 9 am to 5 pm. If they are in need of shelter outside those hours provide them with the hotline: Statewide Domestic Violence Hotline 1 800 334 2836 tell them to press 2 for Spanish.*

YesNo
Which one or more of these apply? / ¿Cuál o más de estos se aplican?*

Intimate Partner Violence / Violencia domestica entre parejaSexual Abuse / Abuso sexual11+ years Child Sexual Abuse / 11+Años Abuso sexual niño (Write Name and DOB of child in notes)Dating Violence / Violencia en el noviazgoStalking / Acecho
VOV Client Demographic*

DV/SA/Stalking SPANISH speaking ClientAll English only speaking refer automatically to DV Hotline for immediate 24/7 assistance: 1-800-334-2836
VOV: What is your need related to (one or more are required for VOV direct assistance):*

Temporary Protection Order Orientation/Assistance: Abuser must be GA resident. Client must know where abuser resides.DV/SA open court case needs assistance contacting Victims Advocate and/or DA/Solicitors officeChild support (Must know address of abuser and employment, must not be living with abuser, Must be Divorced or never married with responding party If added to list case manager maintains discretion on completing application)Victims Compensation Program: must have police report.Financial assistance (must be county LAA currently has funding for)Seeking SNAP/MA/WIC assistanceAdult or Child Sexual Assault caseDomestic Violence shelterUVISA/VAWANone of the above: Refer out
UVISA/ VAWA Request message: Esta es la Asociación Latinoamericana. Para programar una consulta, complete el siguiente formulario. Alguien se comunicará con usted después del envío del formulario de solicitud de consulta. Envíe el formulario lo antes posible y esté atento a las llamadas. Si el formulario es aprobado, se le programará para dentro del proximo mes. Le agradecemos su paciencia. Si buscan otros recursos además de la consulta, responda a este mensaje y/o seleccione sí en la pregunta "RECURSOS ADICIONALES" en el formulario.
https://thelaa.jotform.com/232893861420964 Por favor incluir todas las paginas del reporte de policia en el formulario.
Is it safe to send you a text message to schedule a call? ¿Es seguro enviarle un mensaje de texto para programar una llamada?*

Yes/Si (Someone who could harm me does not have access to phone/Alguien que podría hacerme daño no tiene acceso al teléfono)No (My phone is being monitored/Mi teléfono está siendo monitoreado)
What is your monthly income? ¿Cuál es el ingreso familiar mensual?
Frequency / Frecuencia:

WeeklyEvery 2-weekMonthlyAnnual
Underserved*

HomelessImmigrants/Refugees/Asylum SeekersLesbian, Gay, Bisexual, Transgender, Queer (LGBTQ)VeteranVictims with Limited English ProficiencyNone
What's your country of origin?
We have noted all of your information. Thank you for reaching out to the Latin American Association during a time of need. A specialized Case Manager will reach out as soon as possible to go over your situation and provide you with needed resources. At that time you can go into detail regarding your situation.

If you are in an emergency now or before the Case Manger contacts you please call inmediatlely 911.

We are sorry you are experiencing this situation we will try to help you as much as possible.

________________________________________________________________

Gracias por considerar a la Asociacion Latinoamericana en este momento de necesidad. Una trabajadora social especializada lo contactara lo antes posible para proveerle con recursos basado a sus necesidades. Cuando usted hable con la trabajadora social en ese momento usted puede compartir su historia.

* Si usted esta en una emergencia ahora o antes de poder hablar con la trabajadora social porfavor llame a el 911.

Sentimos lo que esta pasando estamos aqui para servirlo intentaremos ayudarlo lo mas que podamos.
What is your primary language?/ Cuál es su idioma principal?

Spanish / EspañolEnglish / InglésOther
Your age / Su edad
Spouse/Domestic Partner Gender/ Género de esposo/pareja

Female / MujerMale / HombreNonbinaryPrefer not to answer / Prefiero no contestarOther
Did client enter with the CBP 1 application

YesNo
Have you been serviced at other organizations

YesNo
What other organizations:
Spouse/Domestic Partner age / Esposo/pareja 1
Child 1 gender / Género de hijo 1

Female / MujerMale / HombreNonbinaryPrefer not to answer / Prefiero no contestarOther
Child 1 age / Edad de hijo 1
Child 2 gender / Género de hijo 2

Female / MujerMale / HombreNonbinaryPrefer not to answer / Prefiero no contestarOther
Child 2 age / Edad de hijo 2
Child 3 gender / Género de hijo 3

Female / MujerMale / HombreNonbinaryPrefer not to answer / Prefiero no contestarOther
Child 3 age / Edad de hijo 3
Child 4 gender / Género de hijo 4

Female / MujerMale / HombreNonbinaryPrefer not to answer / Prefiero no contestarOther
Child 4 age / Edad de hijo 4
Transportation / Transporte

No transportation / No tengo transportOwn vehicle / Automóvil propioUse public transportation / Utilizo transporte públicoWalk / CaminoFamily or friends / Familia y amigosUse Lyft or Uber / Utilizo Lyft o UberUnknown / Desconozco
Nivel de educación / Level of education

0 -89-12/Non-gradGEDHS Grad12+Some Post 2dCollege GradGraduateUnknownOther
Date of Release from DHS / Fecha de salida de DHS

MonthDayYear
Date
Way of entry into the U.S / Manera de entrada a los EEUU

Without inspection / Sin inspecciónWith Visa / Con VisaParoleAsylum/AsiloOther
Are you looking for asylum? /Esta buscando asilo?

Yes / SíNo
What is the reason for asking for asylum? / Cuál es la base de asilo?

Persecution of Race/ Persecución de RazaPersecution of Religion/Persecución de ReligiónPersecution of Nationality/Persecución de NacionalidadPersecution of Membership in particular social group/Persecución de Afiliación a un grupo social particularPersecution of Political opinion/Persecución de Opinión políticaPoverty/PobrezaNo jobs in my country/Falta de trabajo en mi paísVictim of violence/Víctima de violenciaHumanitarian parole/Permiso humanitarioOther
Were you processed at the US border? / Fue procesado por un agente en la frontera

Yes / SíNo
Do you have a document from your entry to the U.S.A? / Tiene un documento relacionado a su entrada (Visa turista, documento de frontera)?

Yes / SíNo
What state did you enter the U.S. through?/Por cuál estado entro a los EEUU?

FloridaTexasGeorgiaCaliforniaOther
How long have you been in the United States?/Cuánto tiempo tiene en Estados Unidos?

Less than a month/Menos de un mes1-6 months/1-6 meses7-12 months/7-12 mesesMás de un año/Over 1 yearOther
A Number or Number of case
What's your reason for leaving your country? / ¿Cuál es la razón por la que deja su país?

By Force / Forcada o fuerzaBy Choice / Por elección propriaOther
If by force, what's the reason? Si es por fuerza, cual es la razón?

Political violence / Violencia politicaWar / GuerraThreats/AmenazasOther
If by choice, what's the reason?

Work / TrabajoStudy / EstudiosBenefits / BeneficiosOther
What service do you need? Cuales servicos necesita?

Public benefits (refugee from certain countries only) Beneficios publicos (refugios de ciertos paises)Housing (ex. Hotel, Homeless Shelter /ej. Hotel, Refugio de hogar)Immigration consultation / Asesoria migratoriaHealthcare Services and Clinics / Cuidado de salud y clínicasClothing / RopaFood Pantry / Despensa de comidaDomestic Violence / Violencia domésticaConsulates / ConsuladosAffordable Housing / Vivienda asequibleBirth Certificate correction / Correcciones de certificado de nacimientoRegister children in schools / Inscribir a los niños en la escuelaA photo ID / Tramitar una identificación con fotoJob/TrabajoOther
Client Resources
- Economy Hotels - click here
- LAA Newcomers Guide - click here
Do you have any family or friends in Georgia?/Tiene familia o amigos en GA?

Yes / SíNo
Do you have photo ID? / Tiene carnet de identification con foto?

Yes / SíNo
Do you have any chronic medical condition that requires medication?/Tiene una enfermedad crónica que requiere medicamento?

Yes / SíNo
What medical condition?/Cuál es la condición médica?
What medication do you need?/Cuál es el nombre del medicamiento?
Do you feel safe now being in the US?/Te sientes seguro en este país?

Yes / SíNo
Do you have stable housing?/Tiene un alojamiento estable?

Yes / SíNo
Do you have transportation?/Tienes alguna transporte?

Yes / SíNo
Do you have access to food?/Tienes acceso a comida?

Yes / SíNo
Do you have an appointment with the immigration department?/Tienes cita con el departamento de inmigración?

Yes / SíNo
Date of the appointment/Fecha de la cita

MonthDayYear
Date
Do you feel comfortable using public transportation?/Se siente cómodo usando transporte público?

Yes / SíNo
What referral or information are you looking for?

Other Legal /Otros Servicios LegalesMental Health / Salud MentalMedical / SaludHousing / AlojamientoChildcare / Cuidado del niñosChild supportFamily wellness / Bienestar de familiaConsulate / ConsuladosCOVID-19Taxes / ImpuestosFire/Flood victim / Victima de incendio or indunaciónLandlord/tenant / Problemas con arrendador/occupanteWage and hours / Salarios y horasEmployment isssues / Problemas del trabajoNotary / Notario PublicoGuzman PsychotherapyJuntos por una vida saludableOther
Intaker name*

GuadalupeMarcelaMassielAretziSilviaOther not listedZadmarys Rodriguez
Enter intaker name

	Yes	No
Do you have food at home? Tiene comida en su hogar
Do you have something to eat this week? Ha comida algo esta semana?
Do you have a job or are you financially able to pay for food? Tiene un trabajo o capacidad para comprar comida?
Are you aware of any other community resource to access food or nutrition outside of the LAA? ¿Conoce algún otro recurso comunitario para acceder a alimentos o nutrición fuera de LAA?
Do you receive food stamps? Have you had food stamp benefits? / Recibe estampillas? Ha recibido estampillas?
Do you have a newborn? Tiene un bebe recien nacido?

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