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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.

¡Bienvenido a la preselección de solicitudes del Departamento de Servicios Humanos! Por favor complete el siguiente formulario para saber si puede ser elegible para los programa(s) que le interesa. La preselección de la aplicación debe tardar menos de 3 minutos en completarse.

Applicant Information

First Name

Last Name

Suffix

Last 4 SSN (Optional)

Date of Birth

Veteran Status

Gender

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". Numbers 0-9, commas and decimals are acceptable values. Do not include "$" dollar signs.

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". Numbers 0-9, commas and decimals are acceptable values. Do not include "$" dollar signs.

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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