OIC's ASCEND A-Squad Intake Form

OIC's ASCEND A-Squad Intake Form
Date

Month Day Year
Date
Name

First Name Last Name
Preferred name or nickname?
What is your Project EXIT Achiever's Name?
What is you relationship to your achiever?

Parent Grandparent Guardian Other
How many children do you have?
What are their ages?
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
Email Address (one that you actually check)
example@example.com
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
Your Birthday

Month Day Year
Date
Your Gender (male, female, other, etc.)
Are you working?

Yes No
If no, please explain.
What is your occupation?
Are you working your dream job?

Yes No
If no, what is your dream job?
What is your highest level of education?

High School Graduate Some College Associate Degree Bachelor's Degree Master's Degree Doctorate Other
If other, please explain.
Do you have reliable transportation?

Yes No
Do you have a disability?

Yes No
If yes, what accommodations are needed?
Do you own or rent?

Own Rent Other
If other, please explain.
Are you living in your dream home?

Yes No
Do you desire homeownership?

Yes No
Do you have a checking/savings account? (for saving, budgeting, and controlling your finances)

Yes No
What kind?

Bank Credit Union Online Banking CashApp Card Other Debit Card
Are you interested in budgeting, saving, or investing?

Yes No
Are you interested in improving your credit?

Yes No
Do you have court-ordered fines or obligations that are hindering your progress?

Yes No
Have you wanted to start a business?

Yes No
If yes, what kind of business?
Do you have an in-home computer?

Yes No
Wifi/Internet?

Yes No
How would you describe your computer skills?

Great Good Okay Poor
How would you like to make things better for you rand your family?
Do you practice self-care?

Yes No
If yes, what kind of self-care?
What are your hobbies?
Are you in a loving relationship?

Yes No
If no, would you like to be?
Do you have an active relationship with a church?

Yes No
Church Name:
Pastor:
What keeps you up at night?
Should be Empty:

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