BHH Intake Survey 
Please complete the following survey as thoroughly as possible. these questions can help us assess your needs, goals, and interests to personalized support you. 

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Email *
Demographic Information
What is your full name? *
How old are you? *
What is your preferred method of communication? *

Do you currently attend school or college? If yes, what grade/year?


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Are you employed? If yes, what type of job do you have?


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Personal Background 

Who do you currently live with (e.g., parents, guardians, independently)?


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Do you have any dependents (e.g., children or family members you care for)? *

What are your interests or hobbies?


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Have you participated in any community programs before? If yes, which ones? *
Goals and Aspirations

What are your short-term goals (e.g., 6 months to 1 year)?


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What are your long-term goals (e.g., 3–5 years)?


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Are you interested in pursuing higher education, vocational training, or a specific career? If yes, what field? *
What skills would you like to learn or improve on? *
Challenges and Needs

What challenges are you currently facing (e.g., financial, educational, personal)?


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Do you have stable housing? *
Do you have access to reliable transportation? *

What support do you think you need to achieve your goals (e.g., mentorship, tutoring, financial assistance)?


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Program Expectations
What do you hope to gain from participating in this program?
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Are there specific workshops, activities, or topics you’d like included in the program?

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How can we best support you during your time in the program?


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Additional Information

Do you have any medical conditions or allergies we should be aware of?

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Are you involved in any extracurricular activities or volunteer work?


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Is there anything else you’d like us to know about you?

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