Services Intake Form Order Number First Name * Middle Initial Last Name * Korean Name Date of Birth Gender * Female Male other Street Address * City * State * Select a State/ProvinceAbraAguascalientesAgusan del NorteAgusan del SurAichiAkitaAklanAlabamaAlaskaAlbayAmerican SamoaAmnat CharoenAn GiangAng ThongAnhuiAntiqueAomoriApayaoArizonaArkansasArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAuroraBa Ria – Vung TauBac CanBac GiangBac LieuBac NinhBaja CaliforniaBaja California SurBasilanBataanBatanesBatangasBeijingBen TreBenguetBiliranBinh DinhBinh DuongBinh PhuocBinh ThuanBoholBukidnonBulacanBuri RamBusan Gwang'yeogsiCa MauCagayanCaliforniaCamarines NorteCamarines SurCamiguinCampecheCan ThoCao BangCapizCatanduanesCaviteCebuChachoengsaoChagang-doChai NatChaiyaphumChanghua CountyChanthaburiChiang MaiChiang RaiChiapasChiayi CityChiayi CountyChibaChihuahuaChon BuriChongqingChumphonChungcheongbugdoChungcheongnamdoChuquisacaCoahuilaCochabambaColimaColoradoCompostela ValleyConnecticutDa Nang, thanh phoDac LacDaegu Gwang'yeogsiDaejeon Gwang'yeogsiDavaoDavao del SurDavao OrientalDelawareDistrict of ColumbiaDistrito FederalDong NaiDong ThapDurangoEastern SamarEhimeEl BeniFloridaFujianFukuiFukuokaFukusimaGang'weondoGansuGeorgiaGia LaiGifuGuamGuanajuatoGuangdongGuangxiGuerreroGuimarasGuizhouGunmaGuyuanGwangju Gwang'yeogsiGyeonggidoGyeongsangbugdoGyeongsangnamdoHa GiangHa NamHa Noi, thu doHa TayHa TinhHai DuongHai Phong, thanh phoHainanHamgyongbuk-doHamgyongnam-doHawaiiHebeiHeilongjiangHenanHidalgoHiroshimaHo Chi Minh, thanh pho [Sai Gon]Hoa BinhHokkaidoHong KongHsinchu CityHsinchu CountyHualien CountyHubeiHunanHung YenHwanghaebuk-doHwanghaenam-doHyogoIbarakiIdahoIfugaoIlan CountyIllinoisIlocos NorteIlocos SurIloiloIncheon Gwang'yeogsiIndianaIowaIsabelaIshikawaIwateJaliscoJejudoJeonrabugdoJeonranamdoJiangsuJiangxiJilinKaesong-siKagawaKagoshimaKalasinKalinga-ApaysoKamphasng PhetKanagawaKanchanaburiKangwon-doKansasKaohsiung CityKaohsiung CountyKeelung CityKentuckyKhanh HoaKhon KaenKien GiangKochiKon TumKrabiKrung Thep Maha Nakhon BangkokKumamotoKyotoLa PazLa UnionLagunaLai ChauLam DongLampangLamphunLanao del NorteLanao del SurLang SonLao CaiLeyteLiaoningLoeiLong AnLop BuriLouisianaMacauMae Hong SonMaguindanaoMaha SarakhamMaineMarinduqueMarylandMasbateMassachusettsMetropolitan ManilaMexicoMiaoli CountyMichiganMichoacinMieMindoro OccidentalMindoro OrientalMinnesotaMisamis OccidentalMisamis OrientalMississippiMissouriMiyagiMiyazakiMontanaMorelosMountain ProvinceMukdahanNaganoNagasakiNajin Sonbong-siNakhon NayokNakhon PathomNakhon PhanomNakhon RatchasimaNakhon SawanNakhon Si ThammaratNam DinhNampo-siNanNantou CountyNaraNarathiwatNayaritNebraskaNegroe OccidentalNegros OrientalNeia Mongol (mn)NevadaNew HampshireNew JerseyNew MexicoNew YorkNghe AnNiigataNinh BinhNinh ThuanNong Bua Lam PhuNong KhaiNonthaburiNorth CarolinaNorth CotabatoNorth DakotaNorthern Mariana IslandsNorthern SamarNueva EcijaNueva VizcayaNuevo LeonOaxacaOhioOitaOkayamaOkinawaOklahomaOregonOruroOsakaPalawanPampangaPandoPangasinanPathum ThaniPattaniPenghu CountyPennsylvaniaPhangngaPhatthalungPhatthayaPhayaoPhetchabunPhetchaburiPhichitPhitsanulokPhra Nakhon Si AyutthayaPhraePhu ThoPhu YenPhuketPingtung CountyPotosiPrachin BuriPrachuap Khiri KhanPueblaPuerto RicoPyonganbuk-doPyongannam-doPyongyang-aiQinghaiQuang BinhQuang NamQuang NgaiQuang NinhQuang TriQueretaroQuezonQuintana RooQuirinoRanongRatchaburiRayongRhode IslandRizalRoi EtRomblonSa KaeoSagaSaitamaSakon NakhonSamut PrakanSamut SakhonSamut SongkhramSan Luis PotosiSaraburiSaranganiSatunSeoul TeugbyeolsiShaanxiShandongShanghaiShanxiShigaShimaneShizuishanShizuokaSi Sa KetSichuanSinaloaSing BuriSiquijorSoc TrangSon LaSongkhlaSonoraSorsogonSouth CarolinaSouth CotabatoSouth DakotaSouthern LeyteSukhothaiSultan KudaratSuluSuphan BuriSurat ThaniSurigao del NorteSurigao del SurSurinTabascoTaichung CityTaichung CountyTainan CityTainan CountyTaipei CityTaipei CountyTaitung CountyTaiwanTakTamaulipasTaoyuan CountyTarijaTarlacTawi-TawiTay NinhTennesseeTexasThai BinhThai NguyenThanh HoaThua Thien-HueTianjinTien GiangTlaxcalaTochigiTokushimaTokyoTottoriToyamaTra VinhTrangTratTuyen QuangUbon RatchathaniUdon ThaniUlsan Gwang'yeogsiUnited States Minor Outlying IslandsUtahUthai ThaniUttaraditVeracruzVermontVinh LongVinh PhucVirgin IslandsVirginiaWakayamaWashingtonWest VirginiaWestern SamarWisconsinWuzhongWyomingXinjiangXizangYalaYamagataYamaguchiYamanashiYanggang-doYasothonYen BaiYinchuanYucatanYunlin CountyYunnanZacatecasZambalesZamboanga del NorteZamboanga del SurZamboanga SibigueyZhejiangZhongwei zip code * Country Select a CountryBoliviaChinaJapanKorea, Democratic People's Republic ofKorea, Republic ofMexicoPhilippinesTaiwanThailandUnited StatesViet Nam Resident of Fairfax County? * yes No Email * if No Email, use first Name Last Initial Birthdate[MMDDYY]@noemail.com Phone Number Country of Birth Select a CountryBoliviaChinaJapanKorea, Democratic People's Republic ofKorea, Republic ofMexicoPhilippinesTaiwanThailandUnited StatesViet Nam Country of Citizenship Select a CountryBoliviaChinaJapanKorea, Democratic People's Republic ofKorea, Republic ofMexicoPhilippinesTaiwanThailandUnited StatesViet Nam Country of Last Residence Select a CountryBoliviaChinaJapanKorea, Democratic People's Republic ofKorea, Republic ofMexicoPhilippinesTaiwanThailandUnited StatesViet Nam Marital Status Married Single Divorced Widowed Do you have a disability? yes no Are you 55 or older? Yes No Are you the head of the household? * yes no If the client is single with no other family members in the same household, they will be considered as head of household Full Name of Head of Household * If you are serving clients from the same household, you MUST list the SAME head of household for both clients. Race of Head of Household * Asian Native Hawaiian/Pacific Islander Black/African American White/Caucasian Amerian Indian or Alaskan Native other/not reported Multiracial Hispanic or Latine? Yes No Do you have a spouse in the US? Yes No Do you have Children in the US? yes no Do you have parents in the US? yes no Do you have siblings in the US? yes no Is there someone in the household enrolled in TANF? * yesNo Is there someone in the household over 55? * yesNo Is there someone in the household have a disability * yesNo Is there someone in the household unemployed? * yesNo do not include dependents in high school or below Family Economic Status Extremely Low (30% MSA) Very Low (50% MSA) Low Income ( 80% MSA) Total # of household members Do you receive any public benefits from a state or federal Agency Medicaid Cash Assistance SNAP (Food Stamps) SSI TANF Please enter any additional public benefits received here: Do you Have documentation of your public benefits with you today? Yes No Do you Have Health Insurance? Yes No What do you need help with? * Naturalization Health Care Referral DACA Renewal CHAP If not listed above, what other services do you require? Intake Date * Case Notes/details