DY Questionnaire
Intake Form
Name of agency person completing form *
Your answer
Agency completing the form *
Name *
Your answer
Age *
Your answer
Your answer
Cell number:
Your answer
Email address:
Your answer
Street address:
Your answer
City, State
Your answer
Zip Code *
Your answer
Race: *
Gender *
High school diploma? *
Highest grade completed *
Accommodations in school *
Number of children living in household:
Number of people living in household:
Benefits currently being received *
Do you require accommodations?
If yes, what do you require?
Your answer
Employed *
If yes, where are you employed? If no, skip
Your answer
If yes, how long have you been employed here?
Your answer
If yes, what is your income (per hour or per year)?
Your answer
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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