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Intake Assessment (USA) 2019
These questions will help us understand your need.
What is your birthday?
What is your visa/case number?
For example, KBL# or BGH#
Do you need assistance changing your name (FNU)?
How many people are there in your family?
When did you arrive in the United States?
US Phone Number
If you do not have a phone number write "N/A" or None.
Current Street Address
For example, 1000 West Wilson Street #107
Are you married?
Name of your wife or husband
Do you have children?
If so, how many children do you have?
Country of Origin
What is the name of your resettlement agency?
Lutheran Social Services / Lutheran Refugee Services / Lutheran Family Services
Church World Service
ECDC / African Community Center
Episcopal Migration Ministries
No Agency - Need Assistance Signing Up
How much do you pay in rent per month?
What kind of lease do you have for your house/apartment?
Examples: 6 months, one year, month to month
Condition of the Home
Do you have any problems with the condition of your home/apartment? We cannot promise to solve every problem, but please give a general description.
Do you know how to drive?
Do you have a US driver's license?
Do you have transportation?
Yes, I have a car.
Yes, I have a bus pass and I know how to take the bus.
No, I do not have a car and there are no buses that I can take.
There is a bus, but I do not have a bus pass or cannot pay to take the bus.
I do not have a car and I do not know how to take the bus.
Are you currently receiving government benefits?
Check all that apply.
Refugee Cash Assistance
WIC (for mothers, babies and children up to 5 years)
Would you like help furnishing your home?
We cannot promise what donations we can get you based on your location, but we will do whatever we can.
What items do you want / need for your home?
We cannot promise what donations we can provide based on your location, but we will do whatever we can.
Dining room table and wooden chairs
Silverware / Plates / Dishes / Cups
Are you currently working?
When did you start working in this job?
If you cannot remember the exact date, pick the closest date as best as you can remember.
Where are you currently working?
What is your work schedule?
How much are you paid (per hour)?
What is your job title or position?
For example: cashier, mechanic, tailor, etc.
How many hours do you work per week?
Do you need assistance finding a job?
Is there anything else you need help with?
How were you referred to No One Left Behind?
If a friend told you to contact No One Left Behind, please provide their name and your relationship to him. For example, "Another SIV, My friend Ahmad" or "My military friend"
What is the best way to contact you (please list phone number or email)?
FOR STAFF (paid or volunteer) ONLY: If you completed or assisted an SIV holder in completing this form, please indicate your name below.
A copy of your responses will be emailed to the address you provided.
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