Section One:

Patient Name:____________________________ Work Phone:__________________________________

Address:________________________________ Home/Cell Phone: _____________________________

City, State, Zip:___________________________ E-mail:______________________________________

Date of Birth:_________________ Gender _____M _____F    Referred By:______________________

Guardian Information, if patient is under age 18:____________________________________________________

__________________________________________________________________________________________

Diagnosis/Symptom Information:________________________________________________________________

__________________________________________________________________________________________

Did you receive Food Stamps or TFA? ______Yes ______No If yes, provide client ID number:___________________________________________

For the last taxable year, did you qualify for earned income credit? ______Yes ______No

Household Members and Monthly Income: If you are receiving only medical benefits, you must report an income and complete Section Two. If you gave a client ID number for Food Stamps or TFA, skip Section Two.

Section Two:

Name

(List everyone in household)

Gross Income and how often it was received. (Indicate if income was received monthly, twice a month, every other week, weekly or annually.

Example: $100/monthly $100/twice a month $100 every two weeks $100 weekly $28,000/annually

Check if

NO income

Earning from work before decuctions

Welfare, child support, alimony

Pensions, retirement, Social Security

All Other Income

1.

2.

3.

4.

5.

6.

Signature and Social Security Number: I certify that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of IMT treatment at no charge (list value of $150/hour), that CSIMT officials may verify the information on the application and check your credit, and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal Laws.

X_________________________________ ______________________________or ___No Social Security Number

Signature of Adult Household Member Social Security Number

Printed Name:__________________________________________________________________

For office use only:

Date Received: ________/________/________ By:____________________________________________

Application Approved Date: ________/________/_________

Application denied because: __Income over allowed amount __Incomplete/missing __Other:________________