Intake & Support Needs Questionnaire
Answer questions about your household, housing stability, safety, benefits, and current needs.
Do you currently work with any type of social worker?
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Yes
No
If yes, please provide the social worker's name, phone number, and agency.
*
In the last year, have you worked with a social worker? If you have filled out above question please select no for this one.
*
Yes
No
If yes, please provide the social worker's name, phone number, and agency.
*
How many children do you have?
*
What are the ages of your children?
*
If your children are school age, where do they attend school?
Are you currently homeless?
*
Yes
No
Are you concerned about becoming homeless within the next 90 days?
*
Yes
No
Are you currently in a domestic violence situation or have you just left one within the last 30 days?
*
Yes
No
Are you currently receiving any benefits from the government? (Includes SNAP, disability, or SSI)
*
SNAP
Disability
SSI
None
Other
Do you or your children have Medicaid?
*
Yes
No
Are you currently employed?
*
Yes
No
If yes, how many hours a week do you work?
*
Do you have access to a vehicle on a consistent basis?
*
Yes
No
What is your top three needs right now?
*
Submit
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