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Initial Intake
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Email
*
Your email
Date
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MM
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DD
/
YYYY
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
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MM
/
DD
/
YYYY
Phone Number
Your answer
Marital Status
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Single
Single parent
Married
Couple (not married)
Spouse/Partner name (first, middle, last)
Your answer
Spouse/Partner Date of Birth
MM
/
DD
/
YYYY
What brought you to your current situation?
*
Your answer
How long have you been in your current situation?
Your answer
Have you applied at Benjamin's House in the past?
*
Yes
No
Have you been a resident at Benjamin's House before?
*
Yes
No
Children
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Yes
No
Child(ren) Names and ages
Your answer
County of residence
Your answer
What city are you calling from?
Your answer
Other states of residence in the last 3 years
Your answer
Do you have transportation?
Yes
No
Clear selection
Are you employed?
*
Yes
No
Where did you sleep last night?
Your answer
Where do you plan to sleep tonight?
*
Your answer
Do you have any history of drug or alcohol use?
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Yes
No
We are required to run a background check. Is there anything we should expect to find?
Your answer
Probation or Parole?
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Yes
No
Probation/Parole officer name and county
Your answer
Any involvement with Social Services? (Working with a Case Manager)
*
Yes
No
Name and County of Social Worker
Your answer
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