FWB_General

What FWB service are you requesting today?
External_Referral_Filter
********* FINANCIAL ASSISTANCE *********
Important Information

Please select the option that best describes your current immigration status. This information is used to identify the appropriate assistance process for your case.

If you are a U.S. citizen or a lawful permanent resident (Green Card holder), please select "Permanent".
Immigration status type
Before we begin, I’ll ask a few questions to add you to our financial assistance intake process. Assistance isn’t guaranteed due to limited resources, but completing the intake lets us review your situation to see if we may be able to help. If that’s okay, we can get started.
*** FINANCIAL ASSISTANCE - PRIORITY QUESTIONS NON PERMANENT STATUS ***
What type of financial assistance do you need?
Have you received a formal eviction or disconnection notice.
Is the head of household in deportation proceedings or currently detained?
How many people live in your household?
How many children under 18 are there in your household?
Is this a single-parent household?
How many household members are age 60 or older?
Do you have any support system?
Does the head of household have a chronic health condition, mental health condition, or disability
English Proficiency
Are you currently experiencing domestic violence?
Are you currently affected by a disaster (fire, hurricane, flooding, etc.)?
What is the employment status of the head of household?
Do you have any employment barriers?
What is your current housing status?
How many months behind are you?
Have you received financial assistance within the last 12 months?
To make sure we don't make a referral to an organization where you are not currently eligible to receive financial assistance, please select all of the organizations where you have received financial assistance within the last year. Select all that apply

Other
*** FINANCIAL ASSISTANCE - PRIORITY QUESTIONS PERMANENT STATUS ***
What type of financial assistance do you need?.
Have you received a formal eviction or disconnection notice.
How many people live in your household?
How many other adults in the household are currently employed?
How many children under 18 are there in your household?.
Is this a single-parent household?.
How many household members are age 60 or older?.
Do you have any support system?
Does the head of household have a chronic health condition, mental health condition, or disability.
Do you receive SSI benefits?
Are you currently experiencing domestic violence?
Are you currently affected by a disaster (fire, hurricane, flooding, etc.)?.
What is the employment status of the head of household?.
Do you received unemployment benefits?.
Do you have any employment barriers?
What is your current housing status?.
How many months behind are you?
Have you received financial assistance within the last 12 months?
To make sure we don't make a referral to an organization where you are not currently eligible to receive financial assistance, please select all of the organizations where you have received financial assistance within the last year. Select all that apply

Other
**** Mensaje Automatic Refer Out ( Permanent y Non Permanent)**
[For internal staff only**]

Special Case – Automatic Refer Out
At this time, our capacity does not allow us to serve clients who:
- Require assistance for more than one month
- Own their property
- Have received financial assistance from LAA within the past year
Please refer these clients to external resources. Text or print out list of resources.

Current_Referred_Out Text Prompt .docx
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** VARIABLES Y CALCULOS FINANCIAL QUESTIONS **
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*** PRIORITY & OUTCOME FIELDS - NON PERMANENT STATUS ***
Puntos_NON_PERMANENT
Priority Value (Non Permanent)
Priority (Non Permanent)
Recommendation (Non Permanent)
*** PRIORITY & OUTCOME FIELDS - PERMANENT STATUS ***
Puntaje people in household NON Permanent
Puntaje Seniors NON Permanent
Puntaje children NON Permanent
Puntos_PERMANENT
Priority Value (Permanent)
Puntos_NON_PERMANENT_PREGUNTAS_ABIERTAS
Priority (Permanent)
Recommendation (Permanent)
Puntaje people live in household PERMANENT
Puntaje children PERMANENT
*** PRIORITY & OUTCOME VARIABLES ***
Puntaje seniors PERMANENT
Puntos_PERMANENT_PREGUNTAS_ABIERTAS
H_Priority
H_Outcome
M_Priority
M_Outcome
L_Priority
L_Outcome
*********** VARIABLES ESPEJO *********
HP - Priority Value (Non Permanent) For HP forms
Priority (Non Permanent) SC
ESPEJO_Recommendation_NON_Permanent
HP - Priority Value ( Permanent) For HP forms
Priority (Permanent) SC
ESPEJO_Recommendation_Permanent
ESPEJO_Mode_Contact_OnLine
ESPEJO_Which LAA FWB center is receiving this client (phone/walk-in)?
ESPEJO_What FBW service are you requesting today?
*** REFERRED OUT FINANCIAL ASSITANCE ***
FA Refer out Resource List
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******* HOMELESS PREVENTION GWINNETT *******
Reason for requesting/needing the assistance
Do you have social security number?
Do you have a GA ID?
What is your income?
Frequency
Do you received government assistance?
What month(s) do you need help with rent?
RENT QUESTIONS
How much do you pay for rent each month?
Is the lease contract under your name?
Is your lease current?
What month(s) do you need help with rent? --- SE CAMBIO, BORRAR DESPUES
Have you received an eviction notice?
How many bedrooms?
UTILITY QUESTIONS
Water
Is the bill under your name?
How much is the total bill(s)?
When is the bill due?

MonthDayYear
Date
Have you received a disconnection notice?
Electricity
Is the bill under your name?
How much is the total bill(s)?
Have you received a disconnection notice?
When is the bill due?

MonthDayYear
Date
Gas
Is the bill under your name?
How much is the total bill(s)?
When is the bill due?

MonthDayYear
Date
Have you received a disconnection notice?
HOTEL STAY QUESTIONS
Hotel name
Hotel Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hotel phone number
Please enter a valid phone number.Format: (000) 000-0000.
# of rooms
Georgia Homeless Management Information System (HMIS) Privacy Policy Notice
RE-HOUSING (Deposit and/or 1st month) questions
Have you been pre-approved?
Do you have a welcome letter?

Other
If you receive assistance, how will you make payments for the following months?
Do you have a job offer?
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********* PUBLIC BENEFITS *********
Full Capacity - Refer Out

DISCLAIMER for other services: Intaker, please read the following to client OR send via text.

Español

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://docs.google.com/document/d/1fgwwdGngXTReN2vhKAptiCfcyOymQP5I21JRm6AVpso/edit?tab=t.0.

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

English

Thank you for contacting the Latin American Association (LAA). At this time, we are not accepting Public Benefits cases, as we have reached our current capacity.

For assistance, you may contact DFCS at 1‑877‑423‑4746 or find your local office and hours here: https://dfcs.georgia.gov/locations

If you need urgent assistance, you may consult other organizations here:

https://docs.google.com/document/d/e/2PACX-1vReWfLyOIegL0eieWyLFuVjvQRQG7zmFKKECY84eV7KS4Ix3yCuGhOUL3-9ndT3ALi_fqyxdXyuehx7/pub

IMPORTANT: These organizations are not affiliated with LAA.

To check the status of your case using the Gateway mobile application, please follow this instructional video:
https://thelaa.org/wp-content/uploads/2023/04/gateway-how-to.pdf
Other FWB Services
Service Requested
Client ID (not case Number) / Número de identificación 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."
Is past due?
Was the customer served within the last four (4) weeks?
Cannot process Send Docs service; the date cannot be expired

Refer back to DFCS or other agency if we did not do the app/renewal.

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
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.
[Staff**] add to jotform, collect documents and make sure you collect:
- Client ID
- DOB
- Document Due Date
- LAA Staff who assisted
  
  If PAST DUE DO NOT TAKE CLIENT - REFER OUT
Calculo_only_Other
[Staff**] IF the client is calling only for CAPS, TANF or Medicaid/PCK it can’t be served.

Please read the following to client OR send via text.

Refer out Stand alones: MA TANF, CAPS***
Thank you for reaching out to the LAA for assistance with your public benefits. At this time we are not accepting any requests for a single application for NON-SNAP applications or Non-WIC applications. As a funded community partner we have to prioritize SNAP & WIC applications/renewals to meet our program goals. If in the future you decide to apply for a “combined application” ( SNAP + other PB) we may be able to assist if we have availability. If you need further assistance with this stand alone application you can 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

If you’re needing urgent Public benefit assistance, contact the following organizations linked here (Important to note these organization are not affiliated to the LAA): English Public Benefits Referral List

Gracias por contactar La Asociación Latinoamericana para asistencia de beneficios públicos. No estamos aceptando solicitudes para aplicaciones singulares que no son de estampillas. Como socio comunitario financiado por el gobierno, tenemos que priorizar solicitudes de Estampillas para cumplir con los objetivos de nuestro programa. Si usted decide en el futuro aplicar para una “aplicación combinada” (Estampillas/EBT + otro beneficio público) es posible que podamos ayudar si tenemos disponibilidad. Si necesita asistencia con su aplicación singular, usted 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

Si necesita ayuda urgente, consulte otras organizaciones aquí (IMPORTANTE: Estas organizaciones no están afiliadas a la LAA):  Beneficios Publicos - Referral List - Spanish - Copy

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 
EBT Issues
********* VOV *********
VOV Client Demographic
[STAFF] Read/text to client

At the moment, our program has limited capacity, and we currently have one part-time case worker available. Because of this, we may not be able to provide the level of direct assistance that we would like right away.

If you need immediate confidential support, we encourage you to contact the Statewide Domestic Violence Hotline at 1-800-334-2836. The hotline is available 24 hours a day and can connect you with advocates and resources throughout the state. Here is a list of other resources:

VOV_Resource_List2025_PDF
Status_of_Completion
Do you feel safe right now?
If the client feels in danger, please ask them to call 911 immediately.
Which one or more of these apply?
Are you in need of shelter?
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
What is the safest way to contact you?
What is a safe phone number or email?
Safe phone number
Please enter a valid phone number.Format: (000) 000-0000.
[FOR STAFF] *** If it is a client that is illiterate, elderly, or clients who don’t have any other family members or support who can help– client can be added to JF and our team will support. But please collect within the intake notes:
- Name
- DOB
- Phone number
- Address
- Client ID
- Email
Safe email
example@example.com
English:

 If you need assistance with any of the following EBT-related issues, please follow the appropriate steps based on your situation:
- Activating a new EBT card: Visit the ConnectEBT website or refer to the ConnectEBT packet provided.
- Establishing a PIN: Please call 844-604-0009.
- Issues accessing, creating, or a blocked ConnectEBT account: Submit one EBT Cardholder Assistance Request form through the online webform.
Español:
 Si necesita asistencia con alguno de los siguientes problemas relacionados con EBT, por favor siga las instrucciones correspondientes según su situación:
- Activación de una nueva tarjeta EBT: Visite el sitio web de ConnectEBT o consulte el paquete de ConnectEBT proporcionado.
- Establecer un PIN: Llame al 844-604-0009.
- Problemas para acceder, crear o cuenta de ConnectEBT bloqueada: Complete un solo formulario de solicitud de asistencia para titulares de tarjetas EBT a través del sitio web.
Is this phone/email being monitored?
May we leave a voicemail or message?
What is the safest time to contact you?
Are there children or dependents at home?
VOV: What is your need related to (one or more are required for VOV direct assistance):
At this time, we are unable to provide the services you are seeking. We kindly encourage you to contact the Georgia Statewide Domestic Violence Hotline at 1-800-334-2836 (press 2 for Spanish). This confidential hotline is available 24 hours a day, 7 days a week. Additionally, we invite you to explore the helpful resources available through the following links:

GENERAL RESOURCES:

https://drive.google.com/file/d/1e79Jfsk6hcKqksGXMglDx8VvMEaIYN5Z/view?usp=sharing

LEGAL RESOURCES: Free legal information for the immigrant community

Learning Center -Immi

IMMIGRATION RESOURCES:

Spanish Immigration Attorney Referral 11.24.pdf
********* EMERGENCY FOOD ASSISTANCE *********
Do multiple families live in this house or apartment?
Family
Underserved
Address (FP)

Street Address

Apartment

CityState / Province

Postal / Zip Code
Zip Code (FP)
County (FP)
City(FP)

Approximately how much do you receive each month in food stamp (SNAP) benefits?
How many people do you prepare food for?
How many household members are 60 or older?
How many children under 18 are there in your household?
Gwinnett Appointment
Pounds of Food
Calculo stamps
********* AGING AND DISABILITY *********
Is the service for yourself?
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Name (AD)

First NameLast Name
County (AD)
Phone Number (AD)
Please enter a valid phone number.Format: (000) 000-0000.
Date of birth (AD)

MonthDayYear
Date
Gender (AD)
Ethnicity (AD)
Race (AD)
Marital Status (AD)
Immigration status type (AD)
How many members are in your household? (AD)
Do you receive any of these benefits?
Limitations
Preferred method of contact
Interested in senior club?
Client type
********* ASSESSMENT CENTER *********
Senior Club: Adulto Mayor
Assessment Center - Screening Form
Aging & Disability - Service Requested

Other
********* HEPI *********
HEPI - Screening Form
********* CLOTHING ASSISTANCE *********
How many family members will receive clothing assistance?
********* EXTRA ASSITANCE *********
Gwinnett FoodCard
Gwinnett BusPass
Gwinnett GasCard
Flag Cards
Intake Notes

Rows	Yes	No
Your food consumption decrease due to lack of income?
Do you have a job or are you financially able to pay for food?
Are you aware of any other community resource to access food or nutrition outside of the LAA?
Do you receive food stamps? Have you had food stamp benefits?
Do you have a newborn?

********* FINANCIAL ASSISTANCE *********

*** FINANCIAL ASSISTANCE - PRIORITY QUESTIONS NON PERMANENT STATUS ***

*** FINANCIAL ASSISTANCE - PRIORITY QUESTIONS PERMANENT STATUS ***

**** Mensaje Automatic Refer Out ( Permanent y Non Permanent)**

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** VARIABLES Y CALCULOS FINANCIAL QUESTIONS **

*************************************************

*** PRIORITY & OUTCOME FIELDS - NON PERMANENT STATUS ***

*** PRIORITY & OUTCOME FIELDS - PERMANENT STATUS ***

*** PRIORITY & OUTCOME VARIABLES ***

*********** VARIABLES ESPEJO *********

*** REFERRED OUT FINANCIAL ASSITANCE ***

*************************************************

******* HOMELESS PREVENTION GWINNETT *******

*************************************************

********* PUBLIC BENEFITS *********

********* VOV *********

********* EMERGENCY FOOD ASSISTANCE *********

********* AGING AND DISABILITY *********

********* ASSESSMENT CENTER *********

********* HEPI *********

********* CLOTHING ASSISTANCE *********

********* EXTRA ASSITANCE *********

* FINANCIAL ASSISTANCE *

* FINANCIAL ASSISTANCE - PRIORITY QUESTIONS NON PERMANENT STATUS *

* FINANCIAL ASSISTANCE - PRIORITY QUESTIONS PERMANENT STATUS *

** Mensaje Automatic Refer Out ( Permanent y Non Permanent)

VARIABLES Y CALCULOS FINANCIAL QUESTIONS

* PRIORITY & OUTCOME FIELDS - NON PERMANENT STATUS *

* PRIORITY & OUTCOME FIELDS - PERMANENT STATUS *

* PRIORITY & OUTCOME VARIABLES *

*** VARIABLES ESPEJO *

* REFERRED OUT FINANCIAL ASSITANCE *

* HOMELESS PREVENTION GWINNETT *

* PUBLIC BENEFITS *

* VOV *

* EMERGENCY FOOD ASSISTANCE *

* AGING AND DISABILITY *

* ASSESSMENT CENTER *

* HEPI *

* CLOTHING ASSISTANCE *

* EXTRA ASSITANCE *