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Destination Tomorrow Client Screening
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* Indicates required question
Name
*
First and last name
Your answer
Address
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Email
*
Your answer
Phone number
Your answer
Would you like to be on our mailing list?
Yes
No
Clear selection
Are you in school?
Your answer
Name of school?
Your answer
Race?
White
Black/African American
Asian
Hispanic/Latino
American Indian/Alaska Native
Native Hawaiian/Pacific Islander
Multi-Racial
Other:
Clear selection
Gender Identity
Male
Female
Trans-Male
Trans-Female
GNC
Other
Clear selection
Sexual Orientation
Gay/Lesbian
Bisexual
Heterosexual/Straight
Queer/Questioning/Unsure
Other
Clear selection
Are you currently employed
Yes
No
Clear selection
If so, where?
Your answer
Do you or your family have health insurance
Yes
No
Clear selection
If yes, where?
Your answer
Are you linked to primary care?
Yes
No
Clear selection
If yes, where?
Your answer
Do you currently have a place to live?
Yes
No
Clear selection
If yes, where do you live?
*
My own apartment
Parents home/apartment
Family members home/apartment
Friends home/apartment
College dorm/residence
Shelter/transitional housing
Have you ever been tested for HIV?
Yes
No
Clear selection
If yes, when?
*
Your answer
What was the result?
HIV positive
HIV negative
I don't know
Clear selection
If HIV+, are you in care?
Yes
No
N/A
Clear selection
Do you or your family receive any of the following entitlements?
Food stamps
TANF
WIC
SSDI
SSI
Clear selection
What is your personal income?
$0 - $9,999
$10,000 - $19,999
$20,000 - $39,999
$40,000 - $59,999
$60,000 - $79,999
$80,000 - $99,999
$100,000 +
Other:
Clear selection
How did you hear about our services?
Friend
Family member
School staff
Counselor
Healthcare provider
Walk-in
Facebook
Internet
Other
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Check off the opportunities, program activities, or services you are interested in?
Career Coaching/Explorations/Readiness Services
Job placement services
Leadership skills training
Job specific training
Continuing Education - GED/HSE/ESL/Certificate/College, etc,
HIV Testing
Housing
Referral for medical/mental health services
Use of space
Clear selection
Submit
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