• BESS PURPOSE INCORPORATED

    BESS PURPOSE INCORPORATED

    Client Intake Form

  • I. General Information:

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  • May we call you?*
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  • Gender:
  • Birthdate
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  • Marital Status
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  • How did you hear about us?
  • In the last year, have you had any major life changes (i.e., domestic violence situation, eviction, new job, residential move, long illness, relationship change, etc.)?*
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  • Are you a Veteran?*
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  • II. Occupational Information - Pathways to Growth

    Focus:Providing education and career development opportunities to promote self-sufficiency.
  • Are you in need of employment*
  • Are you currently employed?*
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  • III. Housing Information- Foundations for Stability

    Focus: Establishing a stable foundation for personal and family well-being.
  • What is your current housing situation?*
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  • What is your most immediate need to stabilize your living situation?*
  • Please select what you are currently in immediate need of to create a stable and secure living environment*
  • Are you currently receiving any professional and/or transitional services, such as, but not limited to, financial assistance on top of your employment pay (if employed), household items (kitchen, furniture, bedding, etc.),counseling, psychiatric services, and/or any other personal care/living and/or health services?*

  • V. Community Support- Strength Through Community

    Focus: Building a supportive network of peers and community connections.
  • Do you feel you have a strong support system to help you navigate challenges?*
  • Would you be interested in joining a peer support group or participating in community service activities?*
  • What type of community resources would benefit you the most right now?*

  • VI. Acknowledgment and Agreement

  • By signing below, I voluntarily request transitional assistance and guidance services from Bess Purpose Incorporated to help address my living challenges and work toward transforming my life. I understand that completing this intake form does not guarantee that services will be provided.

    I further acknowledge that Bess Purpose Incorporated reserves the right to terminate any services at its sole discretion if any information I have provided is determined to be false or fraudulent. Additionally, I understand that during the intake process, I may be asked to discuss sensitive or potentially upsetting information, which is necessary for Bess Purpose Incorporated to assess my eligibility for services, and I agree to participate in this process. 

    *Applying with this application for our services doesn’t guarantee you will be approved and provided with our services. 

    I confirm that my signature below is valid and will be accepted as my legal acknowledgment and agreement to these terms.

  • VII. Applicant's E-Signature

  • By submitting this application, you acknowledge and agree to the following:

    Walk-Through Recordings: For the safety of our staff, all walk-throughs of your property must be recorded. By proceeding, you consent to this recording as a necessary measure to ensure the security and well-being of all parties involved.

    Lease Submission: You are required to upload a copy of your current lease agreement, a mortgage statement, or your letter of housing status. This must include the names of all tenants listed on the lease, including children, to ensure proper documentation and eligibility for services.


    Failure to provide accurate information or comply with these requirements may result in a delay or denial of services. Thank you for your understanding and cooperation in maintaining a safe and transparent process.

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