Baltimore Regional Housing Partnership | -GAIN Pre-Intake Questionnaire

GAIN Pre-Intake Questionnaire

Thank you so much for taking the time out of your day to complete this pre-intake questionnaire. Your GAIN Coach will use your responses to guide the conversation at your intake appointment. The goal of the questionnaire is to gain an understanding of what your starting point is before you set your program goals.

Name*

First Last

Phone*

Email*

Do you have communication accommodation needs?*

Yes

No

Are you employed full-time or part-time?*

Full-time

Part-time

Not employed

Name of Employer

Position Title

Employment Start Date

Benefits in Current Employment (check all that apply)

Health Insurance

Retirement Savings Account

Other

What is the highest level of education you have completed?*

Do you receive any of the following assistance? (check all that apply)*

TANF/TCA

SNAP/ Food Stamps

Medicaid

Children’s Health Insurance Program

Earned Income Tax Credit

If you have children, how many of them receive childcare services?*

Do you have a savings account?*

Yes

No

How much money do you have saved in your account?

Can you provide a bank statement showing the balance?

Yes

No

GAIN Pre-Intake Questionnaire

GAIN Pre-Intake Questionnaire

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