DY Questionnaire
Intake Form
Agency completing the form *
Name *
Age *
Cell number:
Email address:
Street address:
City, State
Zip Code *
Race: *
Gender *
High school diploma? *
Highest grade completed *
Accommodations in school *
Number of children living in household:
Clear selection
Number of people living in household:
Clear selection
Benefits currently being received *
Do you require accommodations?
Clear selection
If yes, what do you require?
Employed *
If yes, where are you employed? If no, skip
If yes, how long have you been employed here?
If yes, what is your income (per hour or per year)?
Have you ever been convicted of a felony? *
Are you a veteran of the military? *
CTT: Housing *
CTT: Employment Stability *
CTT: Career Resiliency/Training *
CTT: Education *
CTT: Childcare *
CTT: Food and Nutrition *
CTT: Transportation *
CTT: Income (Self-Sufficiency Standard) *
CTT: Physical Health *
CTT: Substance Use *
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