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CAI Client Registration Form
This registration form is forย new clients onlyย (not currently receiving services from a CAI program). If you have a question about a program that you currently participate in, please contact that program directly (Fuel Assistance/WIC/Head Start, etc.) Visit ourย contact pageย for a list of all programs.
Our programs serve the following cities and towns in Massachusetts: Amesbury, Boxford, Georgetown, Groveland, Haverhill, Merrimac, Newbury, Newburyport, Rowley, Salisbury, and West Newbury. Some CAI programs also serve Beverly, Essex, Gloucester, Hamilton, Ipswich, Lawrence, Manchester, Rockport, Topsfield and Wenham.
Name
Name
First Name
Last Name
Enter in form of DD/MM/YYYY
Please complete all information below for any additional household members that currently live with you (spouse, children, relatives, etc.).
Household Member 1
Household Member 1
First Name
Last Name
Enter in Format DD/MM/YYYY
Household Member 2
Household Member 2
First Name
Last Name
Enter in Format DD/MM/YYYY
Household Member 3
Household Member 3
Last Name
First Name
Enter in Format DD/MM/YYYY
Household Member 4
Household Member 4
Last Name
First Name
Enter in Format DD/MM/YYYY
Household Member 5
Household Member 5
Last Name
First Name
Enter in Format DD/MM/YYYY
Household Member 6
Household Member 6
Last Name
First Name
Enter in Format DD/MM/YYYY
Please take a moment to complete this pre-assessment. This helps CAI staff to better understand the needs that you may have and allows CAI to provide you with appropriate services, resources and referrals.
1. Are you satisfied with your current employment situation?
2. Do you have the necessary education to reach your goals?
3. Do you have enough income to meet your family’s basic needs?
4. Do you need help to better manage your personal finances?
5. Is your current housing affordable, safe and secure?
6. Are you currently behind on your utility bills?
7. Can you afford to buy balanced meals for you and your family?
8. Does anyone in your life ever frighten, intimidate, or try to control you?
9. Would you like to improve your English writing, reading or speaking skills?
10. Do you have access to adequate medical care?
11. Is anyone in your family currently dealing with a mental health or drug alcohol problem?
12. Do you have access to safe, affordable and appropriate childcare?
13. Are you interested in additional resources for your child and/or parenting support?
14. Are you always able to get where you need to be? Are you satisfied with your available transportation?
Additional Information
Consent to Share Information Internally
Enter in Format dd/mm/yyyy
Consent
By checking this box and filling in my name and date above, I authorize Community Action, Inc. employees to share information included in my CAI Client Registration Application internally with other CAI programs for the purpose of determining eligibility for additional programs and services. I understand that I am not required to share this information and that this authorization will not affect my eligibility for additional services. The authorization is valid for three years, I understand that I may withdraw this consent at any time.

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