Intake Information Form
Please complete all sections below to help us understand your background and current situation.
Full Name
*
First Name
Last Name
Age
*
Email Address
*
example@example.com
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Ethnicity
*
Please Select
Hispanic or Latino
White
Black or African American
Asian
Native American or Alaska Native
Native Hawaiian or Other Pacific Islander
Multi-racial
Other
Prefer not to say
Current Employment Status
*
Employed full-time
Employed part-time
Self-employed
Unemployed
Student
Retired
Unable to work
Other
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have children?
*
Yes
No
How many children do you have?
Please list the ages of your children (separate with commas)
Do you have reliable transportation?
*
Yes
No
Monthly Income (USD)
*
Emergency Shelter, Food Assistance, Clothing, Hygiene Supplies, Baby Supplies, Counseling, Transportation, Safety Plan
Emergency Shelter
Food Assistance
Clothing
Hygiene Supplies
Baby Supplies
Counseling
Transportation
Safety Plan
I certify that the information provided is true to the best of my knowledge. I understand that Healing A Heart Nonprofit Organization will keep my information confidential except where disclosure is required by law or necessary to protect my safety or the safety of others.
*
Yes
No
Do you currently receive:
SNAP
TANF
SSI
Disability
Child Support
Submit
Should be Empty: