Loyal Butterflies Engagement Intake Form
Welcome to Loyal Butterflies!

Thank you for your interest in our services. Please fill out this form so we can get to know you, and tailor our services to better serve you.
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CONTACT INFORMATION
First Name *
Last Name *
Date of Birth
 *
MM
/
DD
/
YYYY
Last 4 Digits of Social Security Number
(Leave this section blank if you do not have or do not want to provide this information.)
Are you homeless?
 *
Address
(If you are homeless, please provide an address where you can receive mail.)
Unit/Apt. Number
(If applicable.)
City
 *
State
 *
Zip Code
 *
Phone Number
 *
(Use XXX-XXX-XXXX format.)
Alternate Phone Number
(If applicable. Use XXX-XXX-XXXX format.)
Email Address
 *
DEMOGRAPHIC INFORMATION
Which best describes your race or ethnicity?
 *
(Select all that apply.)
Required
What is your gender?
 *
(Select the one that best describes your current gender identity.)
What is your primary language spoken at home?
 *
(Select the one that best describes your household language.)
How do you describe your sexual orientation or sexual identity?
 *
(Select the one that best describes your current sexual orientation.)
Are you currently in the military or a veteran?
 *
Have you had any contact with the criminal justice system?
 *
Do you have difficulty understanding English?
Clear selection
Do you have any disabilities?
Clear selection
Are you in or have you aged out of the foster care system?
Clear selection
Are you a single parent?
Clear selection
EDUCATION & EMPLOYMENT
Are you currently in school?
 *
(Mark one that describes your current engagement in schooling.)
What is your highest degree of grade completed?
 *
(Mark one that describes your highest degree of school competed.)
What is your current employment status?
 *
(Mark one that describes your current employment.)
If working part time, are you seeking full-time employment?
 *
INCOME & PUBLIC BENEFITS
How many people are living in your household, including yourself?
 *
What is your estimated annual household income?
 *
(Household income includes all members of a household.)
Do you receive any of these public benefits assistance?
 *
Required
SCOPE OF SERVICES
Which of the following services from Loyal Butterflies are you interested in receiving?
 *
(Select all that apply to your needs or the needs of your household.)
Required
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