Intake Assessment (USA) 2018
These questions will help us understand your need.
Email address *
First Name *
Your answer
Last Name *
Your answer
What is your birthday? *
MM
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DD
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What is your visa/case number? *
For example, KBL# or BGH#
Your answer
Do you need assistance changing your name (FNU)?
How many people are there in your family? *
Your answer
Gender *
When did you arrive in the United States? *
MM
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DD
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US Phone Number *
If you do not have a phone number write "N/A" or None.
Your answer
Current Street Address *
For example, 1000 West Wilson Street #107
Your answer
City *
Your answer
State *
Are you married? *
Spouse Name
Name of your wife or husband
Your answer
Do you have children? *
If so, how many children do you have?
Country of Origin *
What is the name of your resettlement agency? *
How much do you pay in rent per month? *
Your answer
What kind of lease do you have for your house/apartment? *
Examples: 6 months, one year, month to month
Your answer
Condition of the Home
Do you have any problems with the condition of your home/apartment? We cannot promise to solve every problem, but please give a general description.
Your answer
Do you know how to drive? *
Do you have a US driver's license? *
Do you have transportation? *
Are you currently receiving government benefits? *
Check all that apply.
Required
Would you like help furnishing your home? *
We cannot promise what donations we can get you based on your location, but we will do whatever we can.
What items do you want / need for your home?
We cannot promise what donations we can provide based on your location, but we will do whatever we can.
Are you currently working? *
When did you start working in this job?
If you cannot remember the exact date, pick the closest date as best as you can remember.
MM
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DD
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Where are you currently working?
Your answer
What is your work schedule?
Your answer
How much are you paid (per hour)?
Your answer
What is your job title or position?
For example: cashier, mechanic, tailor, etc.
Your answer
How many hours do you work per week?
Your answer
Do you need assistance finding a job? *
Is there anything else you need help with?
Your answer
How were you referred to No One Left Behind?
If a friend told you to contact No One Left Behind, please provide their name and your relationship to him. For example, "Another SIV, My friend Ahmad" or "My military friend"
Your answer
What is the best way to contact you?
Your answer
A copy of your responses will be emailed to the address you provided.
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