Together, we will conquer the systemic barriers to end disparities and crises impacting our communities. Client Intake Form About YouYour Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Your Email Address(Required) Your Phone(Required)Your Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Do you have a valid Driver's license?(Required)YesNoOutstanding Tickets# of People in Household(Required)Please enter a number less than or equal to 100.Current Living Status(Required)Please select oneHomelessRentingHomeownerLiving with Family/OthersLiving in a ShelterCouch SurfingLiving in a HotelSource of Income(Required) W2 Full Time W2 Part Time Self-Employed Social Security / Disability Pension / Retirement VA Disability No income Full time is 40 hours or more per week Annual Household Income(Required)Ethnicity(Required)Please select oneAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherInterested in Education Services?(Required) Resume & Writing Class Soft Skills and Interviewing Financial Capability Credit 101 Entrepreneurship 101 Interested in 1 on 1 Counseling / Coaching Services?(Required) Credit Interviewing Financial Capability Entrepreneurship None Veteran in the Household?(Required)Please selectYesNoIf Yes, Their NameIf No Veteran in the Household Please Enter "N/A"Co-Client NameCo-Client EmailCo-Client Date of Birth MM slash DD slash YYYY Assistance Request Type(Required)Please SelectClothingEmergency ShelterEmploymentFoodPermanent HousingVA BenefitsOtherIf Other Type of Assistance Is Needed, Please SpecifyHow did you hear about our services?(Required) VA Detroit VA Dearborn Volunteers of America Wayne County Veteran Services Facebook Instagram LinkedIn Other (please specify below) If You selected "Other" under the question "How did you hear about our services", please specify:Any Additional information You Would Like Us To Know?May We Email You About This?(Required)YesNoYou agree to receive future emails and understand you may opt-out at any time Upon completion of the intake form a staff member will contact you within 24 hours.CAPTCHA
