Orcas Community Resource Center Client Intake Form

Client Intake Form

Orcas Community Resource Center
Date

MonthDayYear
Contact Information
Name*

PrefixFirst NameLast Name
preferred name and pronoun
she/hers he/his they/their
Date of Birth*

MonthDayYear
Date
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Email
example@example.com
Preferred Method of Contact
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Language
Emergency Contact Name and Phone
Demographic Information

Why do we ask? This information helps us access grants and other funding opportunities to better serve you!
Veteran?

YESNO
Disabled?

YESNO
Gender
Race and Ethnicity
Highest Level of Education
Health Insurance
What brings you to the Resource Center today?
How can we help?*
Housing
Current Housing Situation
Monthly Mortgage or Rent Amount $*
How do you currently heat your home?*

ElectricPropaneWoodOther
Employment
Employment Status*

Full TimePart TimeUnemployedRetiredDisabilityOther
If employed, list employer
Source of Income
Household Information
Household Members
Household Gross Monthly Income (before taxes) for each family member
Support Network
Support Network
Local Resources
Have you sought out assistance previously from OCRC or any other local agencies?

Food BankLions ClubSenior CenterVeteran's AssistanceDSHSOPALCO Project PalCommunity Wellness Program (CWP)OPALCO Energy Assist ProgramDental VanEmergency AssistanceSafe San JuansRental AssistanceTransportation Voucher Program (TVP)Other
Life Evaluation: The Cantril Ladder

The top of this ladder represents the bestpossible life for you, whatever “prospering” looks like in your eyes. The bottom of the ladder represents the worst possible life for you (as the ladder says… “hopeless”).

On which step of the ladder would you say you’re standing on right now, at this very moment in time?

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

On which step do you think you will stand about five years from now?

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

My signature below indicates that all of the information on this form is both true and accurate. OCRC may use this information to determine elibility for programs and benefits as well as provide data to determine local, county, and state program needs. OCRC may transfer the information contained within this document to their private database. OCRC will not use the information contained in this application for any other reason without my written consent.
Signature (required)*

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Client Intake Form

Contact Information

Demographic Information

What brings you to the Resource Center today?

Housing

Employment

Household Information

Support Network

Local Resources

Life Evaluation: The Cantril Ladder