Bess Purpose Client Intake Form

BESS PURPOSE INCORPORATED

Client Intake Form
I. General Information:
Full Name*

First NameMiddle NameLast Name
Preferred Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile No. :*

Area CodePhone Number
May We Call?*

YesNo
Home Number

Area CodePhone Number
May We Call?*

YesNo
Work Number

Area CodePhone Number
May We Call?*

YesNo
E-mail :*
Where the confirmation will be send to
May We Email?*

YesNo
Gender:

MaleFemaleTransgender
Birthdate

MonthDayYear
Date
Marital Status

SingleDivorcedWidowedPartneredMarriedSeparated
Number of Children
Names & Ages of Children
Emergency Contact: Name, Phone Number, Relationship to Client *

0/300
May We Leave A Message With Your Emergency Contact?*

YesNo
How did you hear about us?

Internet SearchInsurance CompanyWord of MouthAdvertisementOther
In the last year, have you had any major life changes (i.e., new job, residential move, long illness, relationship change, etc.)?*

YesNo
If yes, please explain.
Please upload ID*

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Are you a Veteran?*

YesNo
If you are a Veteran, please upload your DD214 (discharge documents)

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II. Occupational Information
Are you currently employed?*

YesNo
If yes, where are you employed? What is your current position?
Do you have any work related stress? If so, what are they?
Please upload proof of employment.

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Are you in need of employment*

YesNo
III. Wellbeing Information
Do you consume alcohol?*

YesNo
If yes, how many times per month do you consume four or more alcoholic beverages in a 24hr period?
Do you engage in recreational/illicit/illegal drug use?*

YesNo
If yes, how often do you engage in recreational/illicit/illegal drug use?

DailyWeeklyMonthlyRarelyNever
Please list the drugs that you use.
Are you currently in a romantic relationship?*

YesNo
If yes, how long have you been in this relationship?
On a scale from 1-10 (10 being the greatest) How would you rate the quality of this relationship?
Do you practice religion?*

YesNo
If yes, what is your faith?
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?*

YesNo
If yes, please list in detail to the best of your ability*
IV. Other Information
List your strengths and what you would most like to improve in your life:
List areas of concern that you feel you may need to develop a stable environment:
List your strengths and what you would most like to improve in your life:
Check what you are in immediate need of (may not necessarily be what you want) to establish a stable livingenvironment (must be able to pick up if available):*

Queen BedTwin BedCribDresserKitchen TableUtensilsBasic Household Necessities
V. Applicant's E-Signature
By signing below, I acknowledge that I have voluntarily chosen to request transitional assistance and guidance services to enable me to combat and overcome my living obstacles and to attempt to transform my life; also, by
signing below, I acknowledge and agree that completion of this intake questionnaire is not a guarantee of provision of services by Bess Purpose Incorporated. Furthermore, I understand and agree that services
potentially provided to me by Bess Purpose Incorporated may be terminated, at any time, at Bess Purposes sole discretion, if any information provided herein is found to be false or fraudulent. I also understand that, during the
intake process as a potential client, I may need to discuss material and information that may be of an upsetting nature, and I agree to do so, in order for Bess Purpose Incorporated to determine my eligibility for services. I acknowledge that by providing my signature below, it will be accepted as a legal signature.
Type Name*
Signature*

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BESS PURPOSE INCORPORATED

I. General Information:

II. Occupational Information

III. Wellbeing Information

IV. Other Information

V. Applicant's E-Signature