Last Name:
First Name:
Middle Name:
Gender: MaleFemale
Have you received services at HST? YesNo
Street Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email Address:
Marital Status: SingleMarriedDivorcedSeparatedWidowDomestic Partner
Race: WhiteBlackAmerican IndianAsianPacific IslanderRefuseAlaskan NativeUnknown
Ethnicity: HispanicNot HispanicUnknown/Refuse
Preferred method of contact: No preferenceDo not contactMailPhoneEmail
Veteran Status: NoYes
Sr
Name
Relationship
Social Security #
Sex
Date of Birth
Place of Birth
Work
1
SelectMaleFemale
SelectYesNo
2
3
4
5
6
7
Is any member of your family receiving any of the following?
Medicaid YesNo
Medicare YesNo
Pension Benefits YesNo
SSI – Supplemental Security Income YesNo
TANF InsuranceYesNo
Dental Insurance YesNo
VA Medical YesNo
Food Stamps YesNo
CHIP YesNo
Gold Card Harris CountyYesNo
Unemployment Benefits YesNo
Medical Insurance YesNo
Child Support YesNo
Workman’s Compensation YesNo
Social Security Income YesNo
Alimony YesNo
I certify that the information I have provided is true and up to date. I understand that providing false or misleading information may result in the loss of eligibility for this program. I also acknowledge that I am responsible for reporting any changes in my financial situation or household composition, and that failure to do so may affect my continued participation. I authorize the sharing of this information with auditors or other relevant parties as necessary to determine my eligibility and ensure the proper delivery of services. Additionally, for any event participation, I authorize the use of my likeness in advertising and marketing efforts.
To access our services, each individual is required to complete an application and participate in a needs assessment interview.
Please bring one of the following for each adult:
State Driver's License or Identification Card (current or expired)
Passport or Visa
U.S. Immigration documents
Student or work ID*
Photo ID from another country
Other forms of photo identification*
*If a non-government issued ID is provided, another form of ID will need to be provided (such as birth certificate, marriage license, social security card, etc.)
Please bring all of the following for each child:
Birth Certificate or Birth Fact Record
Medicaid or CHIP ID cards
Please bring all the documents that you have.
One month's worth of recent pay stubs
If you do not receive paystubs, a completed wage verification letter from the employer will be accepted.
Most recent tax return
Letter of support
Welfare benefit documents (TANF and Food Stamps)
SSI or Social Security certification documents
Unemployment documents / Worker's compensation
Child support documents
Any piece of mail that is delivered through the Postal Service with the patient's name and address.
Please feel free to call 281-699-9991, if you have any questions.
Email – info@helpingseniorsthrive.org
Helping Seniors Thrive is a registered 501(c)3 Non-profit Organization under EIN 33-1809193
