Pre-screening Intake
Thank you for your interest in the Peer Support Specialist program, please fill out this pre-screening intake for eligibility.
Participant Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Zip Code
*
Have you ever been Justice Involved?
*
Yes
No
Not Sure
Approximately, when was the date of your Justice Involvement?
*
-
Month
-
Day
Year
Date
Approximately, when was the date of your Justice Involvement?
*
Month/Year
Are you currently on probation?
*
Please Select
Yes
No
Are you currently on parole?
*
Please Select
Yes
No
Gender
Male
Female
Gender non-conforming/non-binary
Prefer not to answer
Date of Birth:
-
Month
-
Day
Year
Date
Primary Language Spoken at Home:
English
Spanish
Race/Ethnicity:
Native American or Alaskan Native
Asian
Black or African American
African National/Caribbean Islander
Hispanic or Latino
Middle Eastern
Native Hawaiian/Pacific Islander
White (Non-Hispanic/European American)
Multi-racial
Highest Level of Education:
High School diploma or GED
Trade/Vocational training
Some College
2-year college degree (associate's)
4-year college degree (bachelor's)
Advance degree
Marital Status:
Married
Partnered
Single-never married
Divorced
Widowed
Separated
Family Housing:
Own
Rent
Share housing with relatives/friends
Homeless
Temporary (shelter/temporary with relatives/friends)
Which, if any, of the following do you or your family currently receive? (Check all that apply):
Supplemental Nutrition Assistance Program (SNAP/food stamps)
Social Security Disability Income (SSDI)
Medicaid
Earned Income Tax Credit (EITC)
Temporary Assistance for Needy Families (TANF)
Head Start/Early Head Start Services
Unemployment Benefits
Health State Insurance (including children's health insurance)
Supplemental Security Income (SSI)
None of the above
Submit
Should be Empty: