Client Intake Form
What's your First Name?
What's your Last Name?
What's your Home address?
What's your email?
What's your Cell Phone #?
What is your gender?
How do you describe yourself?
a) Black or African American.
b) Latino or Hispanic American.
c) Caucasian or European American.
e) American Indian, Alaska Native, or Native Hawaiian
What's your age group?
46 and up
What's your marital Status?
Married without dependents
Married with dependents
What's your household size?
Do you rent or own your home?
Living with family and/or Friends
What’s your highest level of education?
a) High school graduate.
b) Associate degree
c) Bachelor degree
d) Post Graduate degree
e) Trade license
f) Did not graduate high school
g) Currently in school
What's your employment Statuts
a) I am a full time college student
b) I am a full time trade school student
c) I have a career
d) I have a job
e) I am a part time student with a job
f) I am a full time student with a job
What was your total annual income last year? Consider annual income from all sources before taxes.
a) Less than $20,000.
b) $20,000 to $39,999
c) $40,000 to $79,999.
d) $80,000 or more
e) Don’t know
What type of work do you do or intend to do when you finish school if you are still in school?
a) Manual work such as truck driver, laborer, farm worker.
b) Skilled trade such as plumber, electrician
c) Service worker such as secretary, food service worker, office worker, police officer, and firefighter.
d) Professional worker such as nurse, computer programmer.
e) Other or don’t know.
Type your name belowe to sign. Disclaimer: Action Bridge staff/members take pictures at workshops and other events. We use these pictures to include in promotional materials among other uses
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