ECWC Compassion Program Evaluation Name: ________________________________________________Date: _____________________Phone #: _____________________ Have you been on any compassion programs before with us and/or another collective? If so, which program(s) were you on?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ If you are on a fixed income what is your total monthly income? __________________________ Is there any information that we should know that would help us make a more informed decision? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please attach all supporting documentation to this form. For Internal Use Only Veterans _____ MediCal _____ Sr ______SSI _____ Compassion + ______

Approved by: __________ Duration: ___________ Scan & Entered By: ___________