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.
Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (one that you actually check)
example@example.com
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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?
Submit
Should be Empty: