People Helping People Intake Form
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Email *
Overview date
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Full Name *
How would you describe your gender? *
Required
Street Address *
City *
Zip code *
Mobile Phone *
Email Address *
Date of Birth (Month/Day/Year) *
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How did you hear about our program?
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I believe I employable or can become employable in the next 12 months
 *
Employer (If not working, put N/A) *
Hire Date (If not working, put N/A) *
Title/Position (If not working, put N/A) *
Income (If not working, put N/A) *
Marital Status *
Do you file taxes as female head of household? *
Are you a single mom? *
Are you currently using community, government, and/or church assistance programs? *
Monthly Financial Assistance Amount:
Please check any assistance programs you are currently using: *
Required
Check all of the barriers you face that may prevent long-term successful employment.  *
Required
Number of children living at home (18 and younger) *
Ethnicity *
Race - Please check all that apply *
Required
Country of Origin *
Veteran *
Highest Level of Education *
Housing Status *
Do you have health insurance? If so, who provides it? *
Do your children have health insurance? If so, who provides it? *
How much do you pay per month for health insurance for yourself? (If you don't have insurance, put N/A) *
How much do you pay per month for health insurance for your children/family? (If they don't have insurance, put N/A) *
If you don't have health insurance, why not? (If you have insurance, put N/A) *
People Helping People (PHP) provides services to low-income women+ without regard to race, ethnicity, religion, political affiliation, national origin, or sexual orientation. PHP provides mentoring and coaching services to clients who meet the following eligibility requirements: 1) are eligible to work in the United States, 2) can speak, read, write, and understand basic English, and 3) Have a high school diploma, a GED, or are enrolled in a GED Program. *
I authorize PHP to share pertinent information regarding my case with agencies I currently receive services from. I understand that PHP will protect my personal information to the best of their ability. *
To the best of my knowledge, the information on this form is complete and accurate. Please type name below. *
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