Retriever Essentials Intake Form
In an effort to create a streamlined experience, we have updated our intake forms. Please complete the intake form each time you receive services from Retriever Essentials. These data are being collected for assessment purposes only. All information is voluntary and any identifying information will remain confidential. If you have any questions about our intake process, please email retrieveressentials@umbc.edu.
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Date *
MM
/
DD
/
YYYY
Ethnicity (choose all that apply)
Age
Do you identify as:
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Are you a full time student, part time student, or staff?
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Student status (choose all that apply)
How many hours do you typically work in a week?
Clear selection
Where do you currently live?
Clear selection
If living off-campus, what is your zip code?
Are you or anyone in your family a veteran?
Clear selection
What service are you receiving today? (choose all that apply for this current visit) *
Required
Is this your first time receiving this service from Retriever Essentials? (first time picking up food, first time getting Save a Swipe, etc.) *
From which location did you receive service? *
What is your household size? (indicate a number)
Do you have any feedback about what think Retriever Essentials does well?
Do you have any suggestions for how we could improve our programs or make it easier for you to access our services?
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