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Intake Questionnaire
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Client #
Your answer
Name
Your answer
Date (first time you came to Aileen's) (MM/DD/YYYY)
Your answer
What year were you born in?
Your answer
What is your racial background? Check all that apply.
American Indian/Native Alaskan
Asian/Asian American
Black/African American/African
Native Hawaiian/Pacific Islander
White
Unkonwn
Prefer not to say
Other:
Are you Hispanic?
Yes
No
Unknown
Prefer not to say
Clear selection
What would you describe your gender?
Woman
Man
Unknown
Prefer not to say
Other:
Clear selection
Do you identify as transgender?
Not transgender
Transgender
Unknown
Prefer not to say
Clear selection
How would you describe your sexual orientation? Check all that apply.
Heterosexual/Straight
Gay or Lesbian
Bisexual/Pansexual
Questioning or unsure
Unknown
Prefer not to say
Other:
Are you currently homeless?
Yes
No
Unknown
Prefer not to say
Clear selection
What is the zip code of the area you most often stay at?
Your answer
What city do you live or most often stay in?
Your answer
What language do you prefer to receive services in?
Your answer
Do you have a disability or disabilities? Check all that apply.
Intellectual and/or developmental disability
Physical disability
Sensory or communication disability
Prefer not to say
Other:
How many adults are in your household?
Your answer
How many children are in your household?
Your answer
How much money does your household bring in in a year?
Less than $25,000
More than $25,000
Unknown
Prefer not to say
Clear selection
Have you ever served in the military?
Yes
No
Unknown
Prefer not to say
Clear selection
If you have served in the military, what is your discharge status?
Your answer
If you have served in the military, how many years did you serve in the military?
Your answer
If you have served in the military, what was your last year of service in the military?
Your answer
Are you related to someone who is serving or has served in the military? If so, what is your relationship to that person?
Not related
Minor dependent
Spouse/partner
Surviving spouse/partner
Other dependent adult
Unknown
Prefer not to say
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