North Charleston + (843) 225-1115
West Ashley + (843) 225-3345
Donate to Hope for Healing
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Contact
Donate to Hope for Healing
Home
About
Patients
Partners
Volunteer
Contact
Donate to Hope for Healing
Renewal Eligibility Questionairre 2022
Name
First
Last
Phone
(Required)
Email
Date of Birth
MM slash DD slash YYYY
Are you between the ages of 18 and 64?
Yes
No
Picture ID Required
Max. file size: 300 MB.
Please take a photo of your ID and upload here.
What is the Zip Code where you live?
Proof of Residency Required
Max. file size: 300 MB.
Please take a photo of a current bill with your name and address and upload here.
Do you have health insurance?
Yes
No
Do you have access to health insurance from your employer or spouse’s employer?
Yes
No
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?
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
