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Participant Intake Form
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Day
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Name
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Address
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eSwatini
Sweden
Switzerland
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Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
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Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
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Uruguay
Uzbekistan
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Vatican City
Venezuela
Vietnam
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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4
Date of Birth
MM-DD-YYYY
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5
Email
example@example.com
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6
Phone Number
Please enter a valid phone number.
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7
Preferred Method of Contact - Check all that apply:
Phone Call
Text
Email
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8
Referred by:
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9
Ethnicity
Hispanic or Latino (Mexican, Puerto Rican, Cuban, Other)
Not Hispanic or Latino
I do not wish to provide this information
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10
Race
American Indian or Alaskan
Asian (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other)
Black or African American
Native Hawaiian or other Pacific Islander (Guamanian, Chamorro, Samoan, Other)
White
I do not wish to provide this information
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11
Gender
Male
Female
Non-Binary
None of the Above
I do not wish to provide this information
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12
Check all that apply:
I am at least 18 years old
I can speak / read English
I can speak / read Spanish
I am able to attend weekly classes
I am motivated to learn new ideas
I am willing to build intentional relationships
I have family that supports my involvement with PFC
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13
How would you describe your relationship with drugs / alcohol?
I have had issues with drug / alcohol abuse, but have been in recovery for at least 6 months
I have had issues with drug / alcohol abuse, and I'm still struggling
I have not had issues with any substances
Prefer not to state
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14
Family Information: Who lives with you and what is their relationship to you?
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15
What is your household income? (This information is asked for frequently when we are applying for grants)
$0.00 - $11,999
$12,000 - $19,999
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 or more
I do not wish to provide this information
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16
What changes are you most hoping to make?
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17
What have you tried in the past? What worked and what didn't?
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