MARANATHA
 
527 Lincoln Way East
Phone: (717) 261-1708
  
 
Chambersburg, PA 17201
Fax: (717) 261-1409
  
 
 
   
Maranatha Intake Form
         
INSTRUCTIONS: All fields are required to process form. Where indicated, check in appropriate spaces.  Once received a counselor will call you to setup an appointment to discuss your personal situation.  If you would prefer to print this and mail it feel free to.
Are you a resident of PA?  Y  N
Do you have dependents?    Y     N
If yes, how many?      
What are their ages?      
Are you willing to help yourself?   Y   N
Do you feel there is hope for your situation?   Y   N
Client Name (First, Middle & Last):

 
Address:

  
Telephone Number:
Total gross monthly income: 
How did you hear about us?

       
Comments or suggestions, please let us know:

       
How did you receive this survey ?