New Client Intake Form

Please complete the following form if you are interested in any of our programs and you currently live in the state of Montana in Silver Bow, Jefferson, Beaverhead, Powell, or Madison County. If you live outside of this area please call 406-782-8579 or email meghanb@nahn.com to discuss your needs first.

After clicking submit, be sure to check the email address you provided for instructions on the next steps.

Paper copies of this form are also available upon request.

If you don’t see the form below, please use this link on our sister site. Thanks!

Client Intake Form
Check all that you are interested in.

Applicant's Personal Information

If you don't live in Montana, we can't provide services directly to you.
XXX-XXX-XXXX
XXX-XXX-XXXX
XXX-XXX-XXXX
Please select yes if you expect a non-dependent to live with the applicant in the future.

Applicant's Employment Information

Skip this section if you are not working.
If your pay is not the same every month, please provide an average.
If yes, please complete the next section. If no, skip ahead to the "Demographics" section.

Co-Applicant's Personal Information

Co-Applicant's Employment Information

If your pay is not the same every month, please provide an average.

Demographics

The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of the individual applicants on the basis of visual observation or surname.
Check all that apply

Applicant's Income

Please list the monthly amounts of all sources of income that you receive (Alimony, child support, social security, disability, pension, TANF, SNAP, dependent SSI, etc). If these amounts vary, please give an average monthly amount.
Please list any other sources of income and the monthly amount here (for ex: SNAP $50, SSI $740).

Co-Applicant's Income

Please list the monthly amounts of all sources of income that you receive (Alimony, child support, social security, disability, pension, TANF, SNAP, dependent SSI, etc). If these amounts vary, please give an average monthly amount.
Please list any other sources of income and the monthly amount here (for ex: SNAP $50, SSI $740).

Liabilities/Debt:

Please list any debt you have, including credit cards, auto loans, student loans, etc. Do no includerent or utilities (we will ask for this later).

Applicant's Liquid Funds/Savings/Investments

Please list the approximate value of each if it applies to you.

Applicant's Monthly Expenses

Co-Applicant's Monthly Expenses

Additional Information

For example: property sales, tax refunds, etc.
Sending