Name of the organization that is inputing information

Client Info

If this client has been reported in previous summaries, check this box
Enter exact date OR the first of the month to indicate which month served
Ex: Salvation Army or Hobbs Police Department

Client Family Information

Add together all children, spouses, and anyone within the Client's responsibility

Client Situation

Check all that apply

Assistance Received

How did your organization assist this client (Check all that apply)