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FORM P Community Services of Northeast Texas, Inc.
579 Revised 304 E.Houston ● P.O. Box 427
FEB 19, 2018 Linden, Texas 75563
Initial Needs Assessment Approved for all programs
Place an X in the appropriate box COMMENTS
Household member's name None Some All
Never Sometimes Always
No Maybe Yes
HEALTH AND NUTRITION
Do all your children have their
required immunizations?
Does any one in your home need
prenatal care?
Do you have medications that
Medicaid/Medicare does not pay
BASIC NEEDS
Do you need food?
Do you need clothing?
Do you need personal items?
Do you have transportation?
HOUSING NEEDS
Do you need home buyer
assistance?
Do you need a low interest loan or
grant to repair your home?
CHILD SUPPORT
Is there a court order for you to
receive child support?
Are you actually receiving the
support from that order?
Do you have a child for which there
is no court ordered support?
BUDGETING
Do you have a planned monthly
budget?
OTHER
Are you being neglected or
abused?
Do you need counseling for a
mental illness?
EDUCATION/JOB INFORMATION
(COMPLETE THIS SECTION ONLY IF YOU ARE ABLE TO WORK)
Are you currenty working? Page 10 Version 9.17
If NO, are you registerd with the
Texas Workforce?
Do you have a high school diploma
or G.E.D.?
Would you like to further your
education?
Do you need child care?
