Clone of 2024 Navigation Intake Form

1
Lets start with your contact information

This is necessary for our Resource Navigator to contact you about your meeting.
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Full Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Birthdate* This field is required.
Date
Year
Month
Day
6
Communication* This field is required.Check all that apply
I can receive text messages on my phone
I have regular access to email
I share my phone with others
7
Are you a refugee?* This field is required.
YESNO
8
What is your military affiliation* This field is required.
Active Duty
None
Other
9
Please tell us about your current living situation (check all that apply).* This field is required.Check all that apply
I rent
I own my own home
It is affordable
I know my neighbors
I am physically/emotionally safe
I am comfortable
I like my neighbors
I am homeless or at risk of becoming homeless
Other
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Please enter the address where you currently live.* This field is required.If you are currently experiencing homelessness, please enter "0" in each field.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
How many people, including yourself, do you live with?* This field is required.
12
Do you have concerns about your living situation?* This field is required.
Yes
No
13
What concerns do you have about your living situation?
Huge
Large
Normal
Small
Ok
Ok
14
In the past year, have you or anyone you live with been unable to get any of the following, when it was really needed?* This field is required.Check all that apply
Food
Clothing
Rent/Mortgage
Phone
Internet Access
Medicine or any healthcare
None of these
Other
15
What is the highest level of school that you have finished?* This field is required.
Less than high school diploma
High school diploma or GED
More than high school diploma
16
Do you want help with school or training? (For example: starting or completing job training or getting a high school diploma, GED, or equivalent)* This field is required.
Yes
No
17
Do you have concerns about your child's education needs?* This field is required.
YESNO
18
What is your current work situation?* This field is required.
Full-time work
Part-time or Temporary work
Unemployed
Not employed but not seeking work (e.g., student, retired, disabled, unpaid primary caregiver)
19
Do you want help finding or keeping a job?* This field is required.
Yes
No
20
Do you have any felonies?* This field is required.
YESNO
21
During the past year, what was the total combined income for you and the family members you live with? This information will help us determine if you are eligible for any government benefits.
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What (if any) government benefits are you currently receiving?* This field is required.Check all that apply
SNAP
TANF
WIC
SSI
Other
None of these
23
Do you feel you manage your money well? (For example: budgeting, paying down debt, saving money)* This field is required.
Yes
No
Somewhat
24
Take a moment to describe what you need help with at this time.* This field is required.
25
Who (if anyone) have you already reached out to for help with your current challenges? (Example: this could be a non-profit, a church, a government agency, or even a friend or family member)?* This field is required.
26
In general, would you say your health is:* This field is required.
Very Good
Good
Poor
Very Poor
27
Do you feel like you get enough exercise?* This field is required.
Yes
No
28
In the past month, how much stress would you say you have experienced? (For example: stress is when you feel tense, nervous, anxious, or can't sleep at night because your mind is troubled)* This field is required.
A lot of stress
A moderate amount of stress
Relatively little stress
Almost no stress at all
29
Have you been feeling down, depressed, or hopeless lately?* This field is required.
Yes
No
30
Do you have a physical, mental, or emotional condition that makes it difficult for you to run errands by yourself?* This field is required.
YESNO
31
If you answered yes to the previous question about a physical, mental or emotional condition, please explain.This helps our Navigator to better prepare for your face-to-face meeting.
32
Are you or any of your loved ones struggling with emotional or physical abuse or trauma?* This field is required.
Yes
No
33
If you answered yes to the previous question about abuse or trauma, please explain as much as you are comfortable.This helps our Navigator to better prepare for your face-to-face meeting.
34
Are you seeking resources for addiction recovery or substance use disorders?* This field is required.
YESNO
35
Does everyone in your household have safe and healthy hobbies they enjoy?* This field is required.
Yes
No
Some but not all of us
36
What is your main health insurance?* This field is required.
Medicaid
CHIP Medicaid
Medicare
Other Public Insurance (CHIP)
Other Public Insurance (not CHIP)
Private Insurance
Other
None / Uninsured
37
Do you have concerns about your current health insurance?* This field is required.
YESNO
38
Are you a primary caregiver for a child under the age of 18, or for someone who is chronically ill, frail, or has a physical or mental disability?* This field is required.Check all that apply
Yes - 1 or more children.
Yes - Someone who is chronically ill, frail, or has a disability.
No
39
Do you spend time with or talk to people that you care about and feel close to? (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)* This field is required.
Yes, often
Yes, but not as often as I would like
No
40
Please mark how much you agree or disagree with this statement: I have a spiritual or religious aspect of my life that helps me.
Strongly Agree
Somewhat Agree
Somewhat Disagree
Strongly Disagree
41
Do you get help with day-to-day activities? (For example: bathing, meal preparation, shopping, managing finances)* This field is required.
I don't need any help with day-to-day activities
I get all the help I need
I could use a little more help
42
In the past month, how often have you felt that difficulties were piling up so high that you could not overcome them?* This field is required.
Often
Sometimes
Never
43
What goals would you like help in achieving over the next 90 days?* This field is required.
44
Do you have a family member, friend, or neighbor you can call if you need help?* This field is required.
Yes
No
45
Assesment Type
Navigation Intake Interview
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Total Score
Should be Empty:

Lets start with your contact information