DATE* -----------------------------------
CLIENT NAME* -----------------------------------
CLIENT ADDRESS* -----------------------------------
CLIENT CITY* -----------------------------------
CLIENT AGE* -----------------------------------
CLIENT MARITAL STATUS* -----------------------------------
# OF CHILDREN* -----------------------------------
# OF DEPENDENTS* -----------------------------------
Has the client filed an application to Larrabee before?* -----------------------------------
IF YES, PLEASE PROVIDE DATE (MM/YYYY) OF MOST RECENT APPLICATION AND ACTION TAKEN* -----------------------------------
MAJOR MEDICAL PROBLEMS (limit to 3)* -----------------------------------
SOCIAL WORKER MAKING THE REFERRAL * -----------------------------------
SOCIAL WORKER TOWN* -----------------------------------
SOCIAL WORKER AGENCY* -----------------------------------
SOCIAL WORKER E-MAIL* -----------------------------------
SOCIAL WORKER PHONE* -----------------------------------
PURPOSE OF REQUEST “please describe reason for request”* -----------------------------------
One Time Request (OTR): lists bills separately - utility, medical, dental, rent, etc. (You need to swipe right and left to see all fields.)* -----------------------------------
Upload Bill(s) for Review* -----------------------------------
Monthly Stipend Request (MSR): may be granted up to six months. -----------------------------------
How many months do you anticipate the client will need stipend support?* -----------------------------------
List additional sources of support and/or public assistance that have been, or will be, sought for this request, and the status of request* -----------------------------------
Toggle yes/no for is bill enclosed. -----------------------------------
INCOME (monthly)* -----------------------------------
ASSETS* -----------------------------------
EXPENSES (monthly)* -----------------------------------
DEBT* -----------------------------------
List any health or dental insurance plans which provide coverage for the client* -----------------------------------
Have you and the client discussed health insurance options available pursuant to the Affordable Care Act?* -----------------------------------
Please provide background and any additional information relevant to this request* -----------------------------------
What is the plan to sustain the client when Larrabee funding ceases?* -----------------------------------
Signature - We accept typed names/electronic signatures -----------------------------------
