Toptia Agency
Client Intake Form
Are you filling this application out for a minor?
Yes
No
If this is your application, are you 18 and older?
Yes
No
Name
First Name and Middle
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Gender
Male
Female
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Emergency Contact Relation To You
Are you pregnant?
Yes
No
Are you a Veteran?
Yes
No
Section 2: Housing History
Are you currently homeless or at risk of becoming homeless?
Homeless
Facing Homelessness
Neither (does not effect application)
Current Living Situation
Staying with friend
Transitional housing
Emergency shelter
Rental home
House of your own
With parents
Other
If Other: Please Specify
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have eviction history?
Yes
No
Not sure
If Yes, Please specify
What Type of housing assistance are you seeking, if any?
Rental assistance
Affordable housing placement
Transitional housing
Emergency shelter
Other
If other, please specify
Section 3. Employment History
Are you currently employed?
Yes
No
Current or most recent employer: Include employer's name, your job title, start date, end (if applicable), Reason for leaving
Do you have any certifications, licenses, or trade skills
Yes
No
If yes, please list:
Type a question
Yes
No
If yes, please list any skill or trade that you are interested in:
Are you actively seeking employment?
Please Select
Yes
No
Are you actively seeking employment?
Yes
No
What type of job are you seeking?
Full-time
Part- time
Temporary
Contract
Hybrid/remote
None
Section 4: Background Information
Have you previously been incarcerated?
Yes
No
If yes, please provide details. (Please be honest, we are here to help you. this is your safe zone)
Do you feel that you have faced discrimination or housing/employment challenges due to your background? is yes, please give a brief example
Do you have and pending charges?
Yes
No
Do you feel the charges will affect the ability to secure housing or employment?
Yes
No
Would the system label you:
Please Select
Violent offender
Habitual offender
Other
N/a
Would the system label you
Violent offender
Habitual offender
first time offender
none
Other
If other, please explain
Section 5 : Goals and Future Plans
What are your short term goals for the next 6 months?
What are your long term goals for the next 1-2 years?
How do you think our agency can help you and how can we best support you in achieving these goals?
Before you get to the end of our intake application, Tell us about you! Tell us your story, everyone has one. We as an organization want to know each one of our potential clients personally and help generate personal care plans for each individual. Let us know why should you be apart of this program.
Section 6: Support Services
Do you need assistance with: Select all that applies
Housing
Employment
Resume Building
Interview Preparation
Mental Health Counseling
Trade Skills
Substance Abuse recovery
Financial Literacy Training
Credit Restoration
Transportation Assistance
Document Retrieval (need and Id, social, birth certificate, ssi, etc)
Benefit Applications (ssi, medicaid, snap, fitap, etc)
Clothing For Interviews/ Work
Childcare Services
Expungements
Community Service Hours
Appointment Scheduling Services( dentist, doctor, etc)
Veteran Services
Youth Services
Tutoring
After care
Business Setups (LLC/EIN etc.)
Other
Pour your heart out: What else can we help you with that is not listed?
Authorization
By submitting and signing this form, I acknowledge, and consent to the following:
I understand, have read, and completed this form truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I give consent for all future treatments.
I acknowledge that program holds the right to terminate the sessions at any time.
I understand that withholding information or providing misinformation may result in lack of resources and assistance.
If you are found to be not honest, we will no longer assist you. We cannot help what we dont know!
I understand that my intake information will not be shared/sold/discuss with anyone that is not directly related to Toptia's agency. this information is confidential and will be stored securely.
I understand that by completing this intake form, I am seeking volntary assistance. I consent to the collection and review of my information for the purpose of housing assistance, employment assistance, and any additional support programs.
Date
-
Month
-
Day
Year
Date
Signature
Upload your photo ID
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Submit
Should be Empty: