YWCA Lancaster New Choices Intake Form
Date Format: MM slash DD slash YYYY
Work and Educational Data
Please list amount in each box. Please write 0 in ALL categories that do not apply to you
Could include retirement, investment, stipend, or any other countable income you receive regularly.
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.
Optional Demographic Data:
This information is de-identified and aggregated for program funding purposes only.