Liberation Center Intake Form

Your name *

Last name

Email address *

Phone number *

Phone type

MobileHomeWorkOther

Address *

HomeWorkOther

Country

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Sex/Gender

Select…ManWomanTransgenderOther (Please Specify)Prefer Not to Say

Race

Select…American IndianAlaskan NativeAsianAfrican AmericanWhiteNative Hawaiian/Pacific IslanderMixed RaceOther (Please Specify)Prefer Not to Say

Ethnicity

Select…HispanicNon-HispanicOther (Please Specify)Prefer Not to Say

Veteran

Select…YesNo

Disability?

Select…YesNo

Primary Language Spoken At Home

Select…EnglishSpanishPortugeseOther (Please Specify)

Relationship Status

Select…MarriedPartneredSingleSeparated/DivorcedWidow(er)

Housing

Select…RentOwnLive with Family/FriendsShelterHotel/MotelHomelessPending Eviction

Number of Adults in Household

min: 0 / max: 20

Number of Children Under 17 in Household

min: 0 / max: 20

Do You Have a High School Degree?

Select…YesNo

Do You Have a Job?

Select…YesNo

Do You Have A Need for Childcare?

Select…YesNo

Do You Feel Housing Secure?

Select…YesNo

Do You Always Have Enough Food for Your Family?

Select…YesNo

Are You Always Able to Pay Your Heating And/Or Electricity Bill?

Select…YesNo

Check Any Other Areas of Need

Clothing Insecurity

Hygiene Insecurity

Prenatal/Parenting Support

Substance Abuse Services

Mental Health Services

Baby/Children Items

Medical Insurance

Rent/Mortgage Assistance (Please fill out Financial Assessment Form)

Other

Submit

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