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West Ashley + (843) 225-3345
Donate to Hope for Healing
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Donate to Hope for Healing
Home
About
Patients
Partners
Volunteer
Contact
Donate to Hope for Healing
NEW PATIENT ELIGIBILITY QUESTIONNAIRE
Full Name
Date of Birth
MM slash DD slash YYYY
Phone
(Required)
Email
Are you between the ages of 18 and 64?
Yes
No
Picture ID Required
Max. file size: 300 MB.
Please take a photo of the front of your driver’s license, state ID card, or passport photo page
What is the Zip Code where you live?
Proof of Residency Required
Max. file size: 300 MB.
Please take a photo of a CURRENT utility bill, tax bill, cell phone bill, lease agreement, etc. Your proof must be current (within the last six months) and show the patient’s name and address
Do you have health insurance?
Yes
No
Do you have access to health insurance from your employer or spouse’s employer?
Yes
No
Do you receive Medicaid or Medicare?
Yes
No
Are you a military veteran?
Yes
No
If YES - are you receiving Veterans Administration medical benefits?
Yes
No
Where have you gone for health care in the past?
Have you had a recent injury or illness? Yes? No? If yes, please describe.
Do you plan to seek disability for the injury/illness?
Yes
No
Please note: the Dream Center Clinic does not have the resources to help patients seeking disability- we are happy to have you as a patient, but we will be unable to provide records to attorneys etc.
Total number of people living in your household ages:
0-17
18-64
65+
How many people living in your household are disabled?
How many people bring income to your household, including yourself?
Proof of income required.
Income Sources
Salary/Wages/Commission
Patient’s Monthly Income
Salary/Wages/Commission
Other Household Members’ Monthly Incomes
Other-Odd Jobs/ Works for Family Friends or Neighbors
Patient’s Monthly Income
Other-Odd Jobs/ Works for Family Friends or Neighbors
Other Household Members’ Monthly Incomes
Self-Employed
Patient’s Monthly Income
Self-Employed
Other Household Members’ Monthly Incomes
Unemployment
Patient’s Monthly Income
Unemployment
Other Household Members’ Monthly Incomes
Social Security / Disability
Patient’s Monthly Income
Social Security / Disability
Other Household Members’ Monthly Incomes
Alimony / Child Support
Patient’s Monthly Income
Alimony / Child Support
Other Household Members’ Monthly Incomes
Food Stamps / HUD
Patient’s Monthly Income
Food Stamps / HUD
Other Household Members’ Monthly Incomes
No Income
Patient’s Monthly Income
No Income
Other Household Members’ Monthly Incomes
Total
Patient’s Monthly Income
Total
Other Household Members’ Monthly Incomes
*This section to be completed by Dream Center Staff/Volunteer
Add patient’s income column with other member’s income column for total household income$_____________
Compare household total to the FPG chart at 250% to determine eligibility.
_____ YES - patient is eligible
_____ NO - the patient in not eligible
________________________________ Volunteer Name
