Center for Working Families

Center for Working Families - Intake
Required elements are underlined
CLIENT DETAILS
Name (last, first, middle initial)
Birthdate (month/day/year)

MonthDayYear
Date
Mailing Address:
Street
City
State
Zip
Personal Email
example@example.com
Preferred Phone:

HomeWorkMobile
Home Phone
Mobile Phone
Work Phone
Gender

TransgenderFemaleMaleOtherClient declined to answer
Race:

African American/BlackAmerican Indian/Alaskan NativeAsianBi-racialCaucasian/WhiteHawaiian/Pacific IslanderMulti-racialOtherClient declined to answer
Ethnicity:

HispanicNon-HispanicClient declined to answer
Primary Language (the language most often spoken at home):

EnglishSpanishPolishChineseArabicOtherClient declined to answer
Highest Grade Completed (If you completed education in another country, estimate the equivalent education in the U.S. Note to staff: Note the difference in a case note or employment/education assessment.):

No High School Diploma/EquivalencyHigh School Equivalency (GED, HiSet, TASC)High School DiplomaSome CollegeCollege Certificate (non-credit bearing)College Certificate (credit bearing)Associate DegreeBachelor’s DegreeMaster’s DegreeDoctoral DegreeClient declined to answer
Vocational Training/Bridge Program History:

No vocational training/bridge program history
Vocational Training/Bridge Program History:

Some vocational training/bridge program(s)Completed vocational training/bridge program(s)Client declined to answer
Military Status:

Active DutyVeteranSpouse of Active Duty MemberSpouse of VeteranNever ServedClient declined to answer
Criminal Convictions

Convicted of Misdemeanor(s) onlyConvicted of Felony(ies)No ConvictionsClient declined to answer
Marital Status:

Married living togetherMarried living separatelyWidowedSeparatedDivorcedDomestic PartnerCommon LawClient declined to answer
Household Role:

SelfSpouse/PartnerChildParentStepparentFoster parentGrandparentSiblingAunt/UncleOtherClient declined to answer
A household is 1 or more heads of household & their dependents. This may include people who don’t live together (e.g. child at college, parent in nursing home People living together may not be in the same household (e.g. roommates who don’t blend finances
Your Household Size
FFT Intake
Living Arrangement If you are incarcerated or in an institution such as a rehabilitation facility or a group home and do NOT pay rent, please select “Household staysfor free:

House/apt. is owned by household memberHouse/apt. is rented by household member – subsidizedHouse/apt. is rented by household member – unsubsidizedHousehold stays in the house/apt./room for free (no lease)Household is homeless (without a roof) or in a shelterClient declined to answer
Health Insurance Status (primary insurance only):

Insured through a government program (e.g. Medicaid, Medicare, SCHIP)Private insurance through a household member’s employerPrivate insurance (not through a household member's employer), unsubsidizedPrivate insurance (not through a household member's employer), partially or completely subsidizedNo insurance at allClient declined to answer
Health Insurance Status (primary insurance only):

Digital Literacy/Computer InstructionFinancial Education/CounselingClient declined to answer
Primary Interest at Program Entry (select one):
Digital Literacy/Computer Instruction

Primary Interest at Program Entry (select one):Job Placement/Career DevelopmentIncome Supports/Public BenefitsOther
Working at program entry? Please create an Employment record for current job

Employed full timeEmployed full time AND StudentEmployed part timeEmployed part time AND StudentUnemployed and looking for workNoUnable to work due to disabilityOtherStay-at-home caregiver or parentYesRetiredClient declined to answerStudent
In school/training at program entry?

Yes Please create an Education/Training Program record for current school/trainingNoClient declined to answer
This ONLY includes earned income (wages, salaries, tips, etc this is different from the later question about gross annual household income.

Report your actual earned income over the last 12 months. Note that
For past 12 mos, earned income after tax
A full month refers to either (1) the calendar month, or (2) any 4 continuous weeks.
For past 12 mos, # of full months worked
Should be Empty:

Center for Working Families - Intake

CLIENT DETAILS

Mailing Address:

FFT Intake