Family Intake Form

Family Intake Form

Hey, I'm so glad you’re here! This form helps me get to know your family, your home, and what kind of support will truly make a difference. It might take a few minutes to fill out, but I promise it’s worth it. The more I know up front, the better I can tailor my support—and help you move forward with clarity and confidence.
I’m looking for at least 15 hours/week of help at home.

Yes, that's me!

Personal Information
Your name*

First NameLast Name
Occupation*
Do you work from home?*

YesNoSometimes
Your spouse's name

First NameLast Name
Their occupation
Do they work from home?

YesNoSome times
Your current address*

Street Address

Street Address Line 2

CityState

Zip Code
Best number to reach you at*
Best number to reach your spouse at
Email*
example@example.com
Preferred contact method*
Your date of birth*

MonthDayYear
Date
How did you hear about INJOY?*

Household Information
How many people reside in your home?*
How many children live in your home, if any?
What are your children's names and ages?
Are your children enrolled in any activities? If yes, please describe.
Does anyone in the home have special needs? If yes, please tell me more.
Do you have pets? If yes, please list them by breed, name, and disposition.
Approximately how many square feet is your home?*
Do you have a regular housekeeping service?*

YesNo
Does anyone else work in the home? If yes, who?
What languages are spoken in the home?*
Please describe your family values.*

Allergy Information
Does anyone in your house have allergies that I should know about?*

YesNo
If yes, please tell me more.

Documents:

All images will be kept private and are for internal use of INJOY only.
A photo of your driver's license or government issued ID*

Cancelof
Family photo

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A photo of your living room.

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A photo of your kitchen.

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A photo of the laundry room.

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A photo of the playroom

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A photo of bedroom 1

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A photo of bedroom 2

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A photo of bedroom 3

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A photo of bedroom 4

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Send Application:
By clicking the submit button below, I cerity that all of the information provided on this application is true.
Signature*

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