Client Intake Form (Sample)
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2CAB, The Shelter Project – Client Intake Form
Last Name: _______________________________________
First Name: _____________________________
Middle Name: ______________________________
Date of Birth: ____________________
Social Security #: ___________________________
Resident Address: ________________________________ City & State: _______________________________
Mailing Address: ________________________________ City & State ________________________________
Home Telephone: _______________________________Work Telephone: _____________________________
Gender
Total Income: _________________
Male
Female
Applicant’s Statement: I certify that the information I have given on this form is correct to the best of my knowledge
and that it is not provided with the intent to fraud. I hereby acknowledge that the information relating determination of my eligibility may require
verification and/or documentation and by my signature, I authorize other to release such information as may be required for the determination of my
eligibility.
Client’s Signature: ____________________________________
Date: __________________
Please check the boxes that apply to you
Location of Residence:
City of Capitola
City of Santa Cruz
City of Scotts Valley
City of Watsonville
Unic. Mid Santa Cruz County
Unic. North Santa Cruz County
Unic. San Lorenzo County
Unic. South Santa Cruz County
Other – Non Santa Cruz County
Ethnicity/ Race:
Black/ Not Hispanic
White/ Not Hispanic
Hispanic
Native American/ Alaskan
Asian/ Pacific Islander
Other
Education:
0-8
9-12/non grad
High School Grad/GED
12+
2/4 yr college degree
Other Characteristics:
Do you have Health Insurance?
Yes
No
Are you disabled?
Yes
No
Are you a Veteran?
Yes
No
Family Type:
Teen Parent less than 20 yrs:
Single parent/ female
Married
Single parent/ male
Single
2-parent household
Single person
Other Family Characteristics:
2 Adults – no children
Other
Farmer
Migrant Farm worker
Seasonal Farm worker
Housing:
Own
Rent
Homeless
Other
Sources of Family Income:
No Income
CalWorks-Participant
CalWorks-Non-Participant
SSI
Social Security
Pension
General Assistance
Unemployment Insurance
Food Stamps
Veterans Benefits
Long-term Housing Asst.
Employment – other sources
Employment only
Other
CAB, The Shelter Project
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