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EVENTS
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Intake Form
*ALL SECTIONS MUST BE FILLED OUT COMPLETELY*
Please provide complete and accurate information.
CLIENT INFORMATION - Household Member # 1
Name
(Required)
First
Last
DOB (MM/DD/YYYY)
(Required)
MM slash DD slash YYYY
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Gender
(Required)
Female
Male
Non-Binary
Phone
(Required)
Email
(Required)
Emergency Contact
(Required)
Emergency Phone
(Required)
Client Characteristics
Race
(Required)
Select one
Black or African American
American Indian or Alaskan Native
Asian
White
Native Hawaiian or other Pacific Island
Multi-race (two or more)
Select one
Ethnicity
(Required)
Select one
Hispanic or Latino
Not Hispanic or Latino
Highest Level of Education Completed
(Required)
Select one
0-8th grade
9-12th grade/Non-graduate
High School Graduate/Equivalency Diploma
12th grade + Some College
2 or 4 year College Graduate
Graduate of other Postsecondary
Are you disabled?
(Required)
Yes
No
Military Status
(Required)
Active
Veteran
None
Health Insurance (Check all that apply)
(Required)
Medicare
Medicaid
Employment-Based
Direct Purchases
Military (VA)
State Adult's
State Children's
None
Work Status
(Required)
Employed Full-time
Employed Part-time
Retired
Migrant Seasonal Worker
Unemployed (More than 6 months)
Unemployed (Less than 6 months)
Unemployed (Not in Workforce)
Housing Type
(Required)
Rent
Own
Homeless
Other permanent Housing
HOUSEHOLD INFORMATION
Household Type
(Required)
I Live Alone
I’m a Single Parent/Female
I’m a Single Parent/Male
Two Parent Household
Two Adults & No Children
Non-related Adults w/ Children
Multigenerational
Other
Household Size
(Required)
1
2
3
4
5
6
7
8
Total # of Children (age 0-17)
Please enter a number less than or equal to
10
.
Total # of Children (age 18 – 59)
Please enter a number less than or equal to
10
.
Total # of Children (age 60+)
Please enter a number less than or equal to
10
.
Additional Household Members - Household Member # 2
(do not include yourself)
Name
(Required)
First
Last
Gender
(Required)
Select one
Female
Male
Non-Binary
Race
(Required)
Select one
Black or African American
American Indian or Alaskan Native
Asian
White
Native Hawaiian or other Pacific Island
Multi-race (two or more)
Select one
Relationship
(Required)
Household Member # 3
Name
(Required)
First
Last
Gender
(Required)
Select one
Female
Male
Non-Binary
Race
(Required)
Select one
Black or African American
American Indian or Alaskan Native
Asian
White
Native Hawaiian or other Pacific Island
Multi-race (two or more)
Select one
Relationship
(Required)
Household Member # 4
Name
(Required)
First
Last
Gender
(Required)
Select one
Female
Male
Non-Binary
Race
(Required)
Select one
Black or African American
American Indian or Alaskan Native
Asian
White
Native Hawaiian or other Pacific Island
Multi-race (two or more)
Select one
Relationship
(Required)
Household Member # 5
Name
(Required)
First
Last
Gender
(Required)
Select one
Female
Male
Non-Binary
Race
(Required)
Select one
Black or African American
American Indian or Alaskan Native
Asian
White
Native Hawaiian or other Pacific Island
Multi-race (two or more)
Select one
Relationship
(Required)
Household Member # 6
Name
(Required)
First
Last
Gender
(Required)
Select one
Female
Male
Non-Binary
Race
(Required)
Select one
Black or African American
American Indian or Alaskan Native
Asian
White
Native Hawaiian or other Pacific Island
Multi-race (two or more)
Select one
Relationship
(Required)
Household Member # 7
Name
(Required)
First
Last
Gender
(Required)
Select one
Female
Male
Non-Binary
Race
(Required)
Select one
Black or African American
American Indian or Alaskan Native
Asian
White
Native Hawaiian or other Pacific Island
Multi-race (two or more)
Select one
Relationship
(Required)
Race
(Required)
Select one
Black or African American
American Indian or Alaskan Native
Asian
White
Native Hawaiian or other Pacific Island
Multi-race (two or more)
Select one
Household Member # 8
Name
(Required)
First
Last
Gender
(Required)
Select one
Female
Male
Non-Binary
Race
(Required)
Select one
Black or African American
American Indian or Alaskan Native
Asian
White
Native Hawaiian or other Pacific Island
Multi-race (two or more)
Select one
Relationship
(Required)
SERVICES/FINANCIAL ASSISTANCE
Services/Financial Assistance
(Required)
Receives Financial Services
Receives NO Financial Services
Public Assistance Support Receiving (Check All That Apply)
(Required)
SNAP/WIC
HEAP
Public Housing Assistance
Supplemental Security Income (SSI)
Public Assistance/Welfare (TANF/AFDC)
Other (specify):
Specify:
(Required)
INCOME WORKSHEET
Indicate below the frequency # (Freq #) that income is/was earned: Weekly (52), Biweekly (26), Twice a month (24), Monthly (12), Annually (1) Frequency X Income Amount = Total Amount of Income
Employment/Income Data
Member #
Please enter a number from
0
to
8
.
Start (MM/DD/YY)
MM slash DD slash YYYY
End (MM/DD/YY)
MM slash DD slash YYYY
Source #
Select one
1. Agricultural
2. Child Support/Alimony
3. Disability
4. DSS Budget Sheet
5. Employment
6. Military
7. Other
8. Retirement Pension
9. Scholarship
10. Self-Employment
11. Social Security
12. Suppl. Security Insurance (SSI)
13. Tax Form(s)
14. Unemployment Insurance
15.Worker’s Compensation
Employer Name:
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Freq #
Select one
Weekly (52)
Biweekly (26)
Twice a month (24)
Monthly (12)
Annually (1)
Income Amount
Total Amount of Income
Member #
Please enter a number from
0
to
8
.
Start (MM/DD/YY)
MM slash DD slash YYYY
End (MM/DD/YY)
MM slash DD slash YYYY
Source #
Select one
1. Agricultural
2. Child Support/Alimony
3. Disability
4. DSS Budget Sheet
5. Employment
6. Military
7. Other
8. Retirement Pension
9. Scholarship
10. Self-Employment
11. Social Security
12. Suppl. Security Insurance (SSI)
13. Tax Form(s)
14. Unemployment Insurance
15.Worker’s Compensation
Employer Name:
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Freq #
Select one
Weekly (52)
Biweekly (26)
Twice a month (24)
Monthly (12)
Annually (1)
Income Amount
Total Amount of Income
TOTAL HOUSEHOLD INCOME
Has means of Transportation?
(Required)
Yes
No
Walk-in or appointment for first visit?
(Required)
Walk-in
Appointment
What programs and/or services would you like to see at PEACE, Inc.?
(Required)
Big Brothers Big Sisters (BBBS)
Head Start / Early Head Start
Energy & Housing Services
Family Resource Centers
Foster Grandparents
Frank DeFrancisco Eastwood Community Center
Free Tax Prep
Senior Nutrition Program
Senior Supports
Select All
Notes:
CERTIFICATION STATEMENT
(Required)
I certify
I certify that the information in this document is true and accurate. I also understand that should verification show that any part be false, participation may be terminated. I also understand that the information contained will be held in confidence and be used to determine eligibility and program planning. I understand that this information may be shared with another Agency.
Client Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.
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