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 you?*

YesNo
Home Number

Area CodePhone Number
Work Number

Area CodePhone Number
E-mail :*
Where the confirmation will be send to
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
How did you hear about us?

Internet SearchIndependent AgencyWord of MouthAdvertisementOther
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.)?*

YesNo
If yes, please explain.
Please upload your proof of Identification*

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Are you a Veteran?*

YesNo
If you are a Veteran, please upload your DD214 or your VA Identification Card (discharge documents)

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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*

YesNo
Are you currently employed?*

YesNo
If yes, name of employer?
What is your current position?
Please upload your most current paystub as proof of employment.

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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?*

RentOwnTemporary housing and residing with friends or familyUnhoused or at risk of losing housing.
Please upload a copy of your current lease with all the property residents listed; mortgage statement OR your letter of status proving that you obtained resident/housing verification?*

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What is your most immediate need to stabilize your living situation?*

Housing assistance or subsidies.Financial guidance or budgeting support.Emergency resources (food, clothing, or utilities).
Please select what you are currently in immediate need of to create a stable and secure living environment*

Full BedTwin BedCribDresserKitchen TableUtensilsBasic Household Necessities
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*
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?*

Yes, I have a solid support network.Somewhat, but I need more resources or connections.No, I feel isolated and need more support.
Would you be interested in joining a peer support group or participating in community service activities?*

Yes, I would like to connect with others.Maybe, I need more informationNo, not at this time..
What type of community resources would benefit you the most right now?*

Emotional or mental health support.Networking or resource fairs.Volunteer opportunities to give back.
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
Full Name*
Signature*

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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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BESS PURPOSE INCORPORATED

I. General Information:

II. Occupational Information - Pathways to Growth

III. Housing Information- Foundations for Stability

V. Community Support- Strength Through Community

VI. Acknowledgment and Agreement

VII. Applicant's E-Signature