Community Action Partnership Of San Bernardino County Intake Assessment Form
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1COMMUNITY ACTION PARTNERSHIP OF SAN BERNARDINO COUNTY INTAKE ASSESSMENT FORM
HOUSEHOLD INFORMATION:
Address: _______
_______ City____________________State____Zip_________ Phone:____________Ph.Type:_______Alt.Phone____________ Ph.Type:______
Housing Type:
Apartment
House
Mobile Home
Other
Housing:
Own
Rent
Homeless
Other
Family Type:
Single parent/female
Single parent/male
Two-parent household
Single person
2 Adults – No children
Other
Other Characteristics:
Farmer
Migrant Farm worker
Seasonal Farm worker
HOUSEHOLD COMPOSITION AND DEMOGRAPHICS: (Complete all information for all members. Ed. Level & Income applies only to those 18 years and older.)
HH Name:
DOB_______F /M SSN_______________Ethnicity: H/NH Race:___ Ed.Level:___ H.Insc:Y/N V D L___ LE RS___ M.Income$_________ IS_____ Rel._________
First Middle Last
Name:
DOB________F /M SSN_______________Ethnicity: H/NH Race:___ Ed.Level:___ H.Insc:Y/N V D L___ LE RS___ M.Income$__________ IS_____ Rel._________
Name:
DOB________F /M SSN_______________Ethnicity: H/NH Race:___ Ed.Level:___ H.Insc:Y/N V D L___ LE RS___ M.Income$__________ IS_____ Rel._________
Name:
DOB________F /M SSN_______________Ethnicity: H/NH Race:___ Ed.Level:___ H.Insc:Y/N V D L___ LE RS___ M.Income$__________ IS_____ Rel._________
Name:
DOB________F /M SSN_______________Ethnicity: H/NH Race:___ Ed.Level:___ H.Insc:Y/N V D L___ LE RS___ M.Income$__________ IS_____ Rel._________
Name:
DOB________F /M SSN_______________Ethnicity: H/NH Race:___ Ed.Level:___ H.Insc:Y/N V D L___ LE RS___ M.Income$__________ IS_____ Rel._________
Name:
DOB________F /M SSN_______________Ethnicity: H/NH Race:___ Ed.Level:___ H.Insc:Y/N V D L___ LE RS___ M.Income$__________ IS_____ Rel._________
Use the table below as legend to look up abbreviations and to find the available options to answer the questions above.
Ethnicity:
Race:
Education level:
1st Language (L):
Residency Status (RS):
Income Source (IS):
H:Hispanic
1)African American
1)0-8
1)English
1)U.S. Citizen
1)TANF
NH: Non Hispanic
2)Asian
2)9-12/non-graduate
2)Spanish
2)Permanent Resident
2)SSI
3)Native American
3.)High School Grad./GED
3)Vietnamese
3)Temporary Resident
3)Social Security
4)White
4)12 + Some post secondary
4)Cambodian
4) N/A (Not Applicable)
4)Pension
5)Multi-Race (any 2 listed)
5)2 or 4 yr. college graduates
5)Tagalog
5)General Assistance
7)Other
6)Unemployment Insc.
7)Employment
HH: Head of Household
H,Insc: Health Insurance
D: Disabled (circle if it applies)
LE: Limited English
RS: Residency Status
8) Employment + Other
st
F/M: Female or Male
V: Veteran (circle if it applies)
L: 1
Language
(circle if it applies)
IS: Income Source
9)Other
Applicant’s Signature
Date
Intake Staff’s Printed Name
Community Action Partnership of San Bernardino County
Agency Intake Assessment Form rev10/07
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