Intake Assessment

Client Information:
Name: *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
SSN *
Date of Birth: *

Month Day Year
Date
Home Phone:
Email:
example@example.com
Gender: *

Female Male Transgender Female (MTF) Transgender Male (FTM) Gender non-conforming ☐ Other Client Refused
The following information is collected to meet the statistical data requirements of various agencies that provide grants to us. The information is confidential and not divulged by client name.
Referral Source: *

24 Hour Hotline On-line Law Enforcement Housing Resource Line Other agencies/professionals Family/Friend Social Media Other
Your Education:

Less than 12th grade High school grad/G.E.D. Beyond high school College grad Graduate degree
Your ethnic origin:

African-American Caucasian (not Hispanic) Hispanic Asian or Pacific Islander Native American Other
Household Income:

0 - $14,999 $15,000 - $29,999 $30,000 - $44,999 $45,000 - $59,999 $60,000 - $74,999 $75,000 +
Of your household income, how much do you personally contribute?

0 -$14,999 $15,000 - $29,999 $30,000 - $44,999 $45,000 - $59,999 $60,000 - $74,999 $75,000 +
Do you have a disability?

Yes No
Relationship Status:

Single Married Separated Living Together Divorced Widowed
Primary Language:
Limited English

Yes No
Citizenship:

U.S Citizen Eligible Non-Citizen Non-US Citizen Allowed to Work Ineligible Non-U.S Citizen
Have you ever served in the military

Yes No Currently Active Duty? Yes No
Health insurance coverage? ☐ Yes ☐ No

Medicaid Private
Source of Income:

Employed TANF SSI Worker’s Compensation Veteran’s Disability Unable to Work Other
Domestic Violence Assessment:
Domestic Violence Experience: *

Yes No
If yes, when did the experience occur?
Did you ever receive domestic violence counseling?

Yes No
Emergency Contact: Name
Name
Client Signature *

Clear
Date

Month Day Year
Date
Did anyone assist you in completing this form?

Yes No
Signature of person assisting:

Clear
Phone:
For Staff Use
Date Received: *

Month Day Year
Date
Staff Signature: *

Clear
Program/ Services:
Should be Empty:

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Client Information:

Domestic Violence Assessment:

Emergency Contact: Name

For Staff Use