📋 WELLBEINT RESOURCING PROGRAM INTAKE FORM

📋 WELLBEINT RESOURCING PROGRAM INTAKE FORM

To help us understand your current needs and how we can best support you!
Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
E-mail*
example@example.com
Mobile Number*
Preferred Method of Contact

CallTextEmail
Preferred Time Of Day To Contact

Morning 8am-11amNoon 12pm-3pmEvening 3pm-6pm
Current Living Situation
What is your current housing status?*

Stable housingTemporarily with friends/family (House to House)In transitional housingUnshelteredOther
Do you need assistance with housing or rent?

YesNo
Employment & Income
Current employment status:

Employed Full-TimeEmployed Part-TimeUnemployedSelf-EmployedGig Work (Uber, Doordash, Instacart, Walmart Spark etc.)StudentOther
Would you like help finding employment, training, or income assistance?

YesNo
Education & Skills
Highest level of education completed:

Less than High SchoolHigh School Diploma/GEDSome CollegeAssociate/Bachelor’s DegreeGraduate Degree/Certification
Are you interested in:

Finishing schoolSkill-building or certificationsResume or interview helpOther
Health & Wellness
Would you like prayer?

YesNo
Do you have access to health care or insurance?

YesNo
Are there any mental health or wellness services you’d like help accessing?

TherapySupport GroupsSubstance Use HelpPhysical Health ResourcesOther
Financial Wellness
Would you like support with:

BudgetingDebt managementSaving strategiesCredit Repair or BuildingUnderstanding your financial rightsOther
Do you need help with:

ChildcareTransportationLegal assistanceGovernment Assistance (Food Stamps, Health Insurance, CAP Program)Food securityDigital access (Wi-Fi, devices)Other
Wellbeint Disclosure Notice

Thank you for choosing Wellbeint. Before we begin, please review the following important information regarding your participation in our intake process.

Purpose of Intake
The purpose of this intake form is to gather relevant personal, financial, and/or household information to better understand your current situation and determine how Wellbeint can best support your goals through our educational, financial literacy, or resourcing programs.

Confidentiality Statement
All information you provide will be kept strictly confidential and used solely for program purposes. Your data will not be sold, shared, or disclosed to third parties without your written consent, except as required by law.

Voluntary Participation
Participation in this intake and in any Wellbeint program is completely voluntary. You may choose to withdraw at any time without penalty.

Consent to Contact
By submitting this form, you agree that a Wellbeint representative may contact you via phone, email, or text to follow up on services, questions, or program eligibility.

No Financial Guarantee
Please note that Wellbeint provides educational and resourcing support and does not guarantee credit score increases, financial outcomes, or housing placement. Your personal commitment and actions are essential to your success.

Acknowledgment
By completing, signing and submitting this intake form, you acknowledge that you have read, understood, and agreed to the terms outlined in this disclosure.
Your Signature*

Powered by Jotform SignClear
Should be Empty:

📋 WELLBEINT RESOURCING PROGRAM INTAKE FORM

Current Living Situation

Employment & Income

Education & Skills

Health & Wellness

Financial Wellness