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Application Prescreen
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Application Prescreen

Application Prescreen

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Applicant Information

Welcome to the Human Services Department’s Application Prescreen! Please complete the following form to learn if you may be eligible for the program(s) you are interested in. The Application Prescreen should take less than 3 minutes to complete.

Applicant Information

First Name

Last Name

Date of Birth

Last 4 SSN (Optional)

Gender

Veteran Status

Do you live with a disability?

Race & Ethnicity

Asian

Hispanic, Latino, or Spanish

Native Hawaiian/Pacific Islander

Black/African American

Middle Eastern or North African

White

Indigenous Peoples, Native American, or Alaskan Native

Other

Prefer Not to Answer

Tribal Nation

Other Ethnicity

Address

Street 1

Unit

Street 2

Street 3

City

State

Zip Code

Contact Information

Email Address

Verify Email

Phone Number

Phone Type

Household

What is the total number of adults and children that live in your household?

What is your household's total income for the last 30 days? This is the sum of all household income before taxes or deductions.

If your household has no income to report, please enter "0".

What is your household's total annual income? This is the sum of all household income before taxes or deductions.

If your household has no income to report, please enter "0".

How did you hear about us?

Family/Friend

Justice System (Courts, Corrections, Probation, etc.)

K-12 School

Faith-Based Organization/Church

Non-Profit/Community-Based Organization

Government Department

Training Provider

Other Service Provider

Websites and Social Media

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234 N Central Avenue
Suite 3000
Phoenix, Arizona 85004

Main Line: 602-506-5911

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