Initial Intake
Please fill out completely and to the best of your knowledge. Completing this form DOES NOT guarantee program placement.
Email *
Date *
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First Name *
Last Name *
Date of Birth *
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Phone Number
Have you applied at Benjamin's House in the past? *
Have you been a resident at Benjamin's House before? *
What brought you to your current situation? *
Gender
Clear selection
Marital Status
Clear selection
Spouse/Partner name (first, middle, last)
Children *
Child(ren) Names and ages
County of residence
What city are you calling from?
Other states of residence in the last 3 years
Do you have transportation?
Clear selection
Where did you sleep last night?
Where do you plan to sleep tonight? *
Drug or Alcohol history *
We are required to run a background check. Is there anything we should expect to find?
Probation or Parole? *
Probation/Parole officer name and county
How did you learn about Benjamin's House?
Anything else you want to share about your situation
Submit
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