New Choices Intake Form - YWCA Lancaster

YWCA Lancaster New Choices Intake Form

How did you hear about us?

Friend/family
Television
Radio
Re-entry program
Social media
Referral
Flyer
Other

If "other" above, please describe.

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Home Phone

Work Phone

Email

Date of Birth*

Do you want to receive texts from New Choices?

Are you a US Veteran?

How do you identify your gender?

Do you have any criminal convictions?

Are you experiencing homelessness?

Are you enrolled in Medicaid (MA)?

Ethnicity/Race: Please check all that apply

American Indian/Alaska Native
Hawaiian Native/Pacific Islander
Caucasian/ White
African American/ Black
Hispanic/ Latinx
Non-Hispanic/ Latinx
Multi-racial
Asian/

Is English your first language?

Are you looking for full or part-time work?

Are you an individual with a disability?

Marital Status?

How many children under 18 depend on you for support?

List the ages of your dependent children.

Do you have a partner living with you?

Are there any other people living in your household besides those you have listed above? List their age(s) and relationship(s)

Emergency Contact Phone

Emergency Contact Name

First Last

Work and Educational Data

Are you currently attending school?

If yes, what school and what program?

Highest education level attained

Name of institution

Major/Degree(s)

List any Professional Certificates or Credentials

Are you CURRENTLY employed/working?

If you are working - how many hours per week average?

What is your hourly wage or weekly/monthly/yearly salary?

Do you have an updated resume?

If yes, upload resume below

Drop files here or

Max. file size: 128 MB.

Income Data

Please list amount in each box. Please write 0 in ALL categories that do not apply to you

Partner's earned income (monthly)

Income from all other sources (per month):

Could include retirement, investment, stipend, or any other countable income you receive regularly.

Partner/Child Support (per month)

Assistance Programs:

If the answer is yes to any type of assistance listed below, please write the amount received per month. **Reentry clients should enter 0’s for these categories.

Refugee cash assistance (per month)

Housing Assistance

SNAP/Food Stamps (per month)

Women Infant and Children

TANF/Cash Assistance (per month)

Workers' Compensation Income (per month)

Unemployment Compensation (per week)

Are you nearing exhaustion of Unemployment benefits?

Social Security Disability (per month)

Supplemental Security Income (per month)

Optional Demographic Data:

This information is de-identified and aggregated for program funding purposes only.

Citizenship Status

US Citizen
Permanent Resident
Temporary Resident
Non-US Citizen
Refugee
Other

If "other" above, please describe.