Boynton Beach Patron-Initial Intake
For questions that you cannot answer, please put "N/A" or "none."
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Today's Date *
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Time *
Time
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Last Name *
First Name *
Date of Birth *
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Age
Phone *
Email *
Address
Gender Identity *
Required
What is your marital status *
Language *
Type of Initial contact *
Who provided you this in-take form and how did you find it?
Library or agency referral sources *
What ethnic group do you identify with *
Required
What is your employment Status *
What do you expect  to happen when meeting a Social worker?
Have you received services from any agency?
Clear selection
Are you receiving SSI benefits? *
Do you need help applying for SSI? (Disability) *
In which branch (or branches) of the United States Military have you served? (If you have not served, please answer "Not Applicable") *
If patron is unhoused, please answer the following questions:
Are you currently experiencing homelessness?
Clear selection
If yes, approximately when did it start?
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DD
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Have you been homeless for a full year or had four or more episodes of homelessness?
Clear selection
Where are you currently staying?
Clear selection
Are you currently part of a housing program?
Clear selection
Have you ever experienced any type of trauma? *
Would you like to briefly share your experience? *
If patron is housed, please answer the next two questions:
Do you currently live in adequate/stable housing? *
What type of housing assistance are you seeking? *
How familiar are you with the services you seek? *
Are you currently connected to any agency? *
How often do you visit the library? *
Do you have a library card? *
Would you be interested in any of the following library groups or programs? *
Required
Which of the following resources may benefit you or someone in your household? (Check all that apply) *
Required
If substance misuse problem, specify the substance. *
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