Workshop Intake Form

Cafe y Poder Workshop Intake Form

Center for Changing Lives
Please provide us with the following information. Information collected on this form is used by Center for Changing Lives only and is not shared with any other organization, unless requested for reporting and funding purposes. Your personal information is never shared. Please answer all questions completely. If you have any questions about this form or how we will use this information, please ask us.
PERSONAL INFORMATION

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Name:*
Date of Birth:*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
N/A – I currently lack a fixed, regular nighttime residence.
Email:*
example@example.com
CellPhone:*
HomePhone:
WorkPhone:
Alternate Contact Name & Info:
Marital Status*

Single (never married)MarriedPartneredSeparatedDivorcedWidowed
Gender*

FemaleMaleTransgenderOther
Race*

African American / BlackAsianAmerican Indian / AlaskanBirracialCaucasian / WhiteMultiracialOther
Ethnicity*

HispanicNon-Hispanic
Do you have a criminal background:*

Misdemeanor(s) onlyFelony(ies)BothN/A
HOUSEHOLD INFORMATION

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Head of household?*

YesNo
How many in your household (include yourself)?*
(In total household include the head(s) of the household and the people you are financially responsible for)
How many under the age of 18?*
What language do you most often speak at home?*

EnglishEspañolPolishOther
Living Arrangement*

I own my house/apartmentI rent a housing unitI rent with other households in an overcrowded unitI stay in a unit for freeI am living on the street or in a shelter
What types of cash income are received by any person in the household and who receives what income:*

No IncomeUnemployment Comp.Employment & OtherEmployment ONLYTANF / (AFDC)Social SecurityPensionEarn Fare / Transitional AssistChild SupportSSISSDOther
Total Gross Monthly Household Income:*
In the past 12 months, how many full months (4 continuous weeks) did you work?*
If employed, name of employer:
MEDICAL INFORMATION

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Are you currently insured?*

YesNo
if yes,

MedicaidMedicareCounty CarePrivate Insurance
PROGRAM INTEREST

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What is your primary interest in our services? (select one)*

Job Placement / Career DevelopmentIncome Support / Public BenefitsFinancial Education / CounselingHousing Education / CounselingOther
Client Signature:*

Clear
Date:*

MonthDayYear
Date
Thank you! This information, when combined with all other participant information without your name or identifying information, helps us improve our services! Your responses will be kept confidential.
Should be Empty:

Cafe y Poder Workshop Intake Form

PERSONAL INFORMATION

HOUSEHOLD INFORMATION

MEDICAL INFORMATION

PROGRAM INTEREST