BRHP | HCD Pre-Intake Questionnaire, Pregnancy Referral

HCD Pre-Intake Questionnaire, Pregnancy Referral

Healthy Children Demonstration Pre-Intake Questionnaire (Pregnancy Referral 1)

Pre-Intake Questionnaire
Thank you so much for taking the time out of your day to complete this pre-intake questionnaire. Your counselor will use your responses to guide the conversation at your intake appointment. The goal of the questionnaire is to gain an understanding of what some of your barriers to moving may be and how we can support you along the way.
Which BRHP counselor sent you this questionnaire to complete?
Name*
First Last
Address*
Street Address Address Line 2 City ZIP Code
Email
Home Phone
Cell Phone
Do you have communication accommodation needs?*
- Yes
- No
Do you need to attend workshops offered at special times?*
- Yes, evenings
- Yes, weekends
- No
Emergency Contact
Please list the name and contact information of an emergency contact.
Name*
First Last
Relationship to You
Phone Number*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Household Composition
How many people will be in your household?
How many adults (other than yourself) will be in your household?
Will there be any children in your household?
- Yes
- No
How many children will be in your household?
Are you currently pregnant?
- Yes
- No
- Unsure
Household Adult Information
Please fill in the following information for a household adult (other than yourself).
Name*
First Last
Relationship to You*
Date of Birth*
MM slash DD slash YYYY
Occupation type
Household Adult 2
Please fill in the following information for another household adult (other than yourself).
Name*
First Last
Relationship to You*
Date of Birth*
MM slash DD slash YYYY
Occupation Type
Household Child
Please fill in the following information for a child in your household.
Name*
First Last
Relationship to You*
Date of Birth*
MM slash DD slash YYYY
Student Grade or Type (If applicable)
Name of School (If applicable)
How satisfied are you with your child's current school this year?
- Very satisfied
- Somewhat satisfied
- In the middle
- Somewhat dissatisfied
- Very dissatisfied
Household Child 2
Please fill in the following information for another child in your household.
Name
First Last
Relationship to You*
Date of Birth*
MM slash DD slash YYYY
Student Grade or Type (if applicable)
Name of School (if applicable)
Household Child 3
Name
First Last
Relationship to You
Date of Birth
MM slash DD slash YYYY
Student Grade or Type (If applicable)
Name of School (If applicable)
Household Child 4
Please fill in the following information for another child in your household.
Name
First Last
Relationship to You
Date of Birth*
MM slash DD slash YYYY
Student Grade or Type (If applicable)
Name of School
Household Child 5
Please fill in the following information for another child in your household.
Name
First Last
Relationship to You
Date of Birth*
MM slash DD slash YYYY
Student Grade or Type (If applicable)
Name of School
Children and School
Do you have full legal custody of each of your minor children and do all of your minor children live in your household?
- Yes
- No
- No, custody belongs to another household adult
Do all of your school-aged children receive free or reduced price lunch?
- Yes
- No
- I do not have any school-aged children
How are your children's attendance records at school?
- Excellent (Rare days missed)
- Good (Average days missed)
- Poor (days often missed)
- Very poor (serious truancy issues)
- There are no school-aged children in my household
If one or more of your children's attendance is poor, please explain why and indicate any supports that would help improve the situation.
Do you plan to transfer all household children to local schools upon moving?
- Yes
- No
- Unsure
- I don’t have any school-aged children
If you don't plan to transfer your children or are unsure, please explain.
How do you expect your household's children to handle the move and a potentially more challenging school environment?*
- Very Well
- Well
- Poorly
- Very poorly
- There are no school-aged children in my household
Which of the following describes your participation in your children's school activities: (Select all that apply)
- I do not engage much
- I help my children with their homework
- I maintain active communication with my children’s teacher(s)
- I attend PTA meetings
- I volunteer for school activities/trips
- I don’t have any school-aged children
Household Special Needs
Does anyone in your household have special needs?
- Yes
- No
Do you need any of the following accommodations due to a disability? (Select all that apply)
- Fully accessible unit
- unit on the ground floor
- H/V features
- Extra bedroom for medical equipment
- Live-in aide
- In-home BRHP counseling
Education and Training
What's the highest level of education you have completed?
- Elementary school
- Some high school
- High school diploma
- GED
- Some college
- Associate’s degree
- Bachelor’s degree
- Some grad school
- Master’s degree
- PhD
Have you completed any of the following: (select all that apply)
- Vocational/technical training
- Skills training program
- Other training or certification
Have you completed any of the following certifications? (Select all that apply)
- License daycare provider
- CNA/GNA
- Pharmacy technician
- Healthcare Administration/Billing
- License Beautician/Cosmetologist
- Corrections
- IT certification(s)
- Other
Are you currently enrolled in an educational program?
- Yes
- No
If you're enrolled in an educational program, what institution?
Are you interested in making further progress with your education?
- Yes
- No
Household Income
TCA
SSI
SSDI
Salary
Hourly wage and hours worked per week
Child support
Unemployment
Self-employment income
Veteran's benefits
Other income
Household Assistance
Do you receive any of the following assistance?
- Food stamps
- WIC
- Childcare assistance
- Transit assistance/mobility
- Utility assistance
- Medicaid/Medicare
- Other
How much do you receive in food stamps?
Within the last 12 months, did you worry that your food would run out before you got money to buy more?
- Yes, often
- Yes, sometimes
- No
- Unsure
Do you have medical insurance?
- Yes
- No
If you have insurance, what is the name of your insurance?
Does your child have medical insurance?
- Yes
- No
If your child has insurance, what is the name of the insurance?
During the past 12 months, was there any time when your child needed medical care but did not get it?
- Yes
- No
If yes, did your child not get care for any of the following reasons?
- You couldn’t afford it
- You didn’t have transportation
- You didn’t know whom to see
- You couldn’t go because you had to work or take care of your family
- You didn’t have insurance/ insurance wouldn’t cover enough of the cost
Please select all that apply.
Employment
What is your current employment status?
- Employed, full-time
- Employed, part-time
- Employed, temporary job
- Unemployed
Who is your employer?
In what county is your employment located?
- Anne Arundel County
- Baltimore City
- Baltimore County
- Carrol County
- Harford County
- Howard County
In what city/part of town is your employment located?
How long have you been at your current job?
- Less than 6 months
- 6 months to 1 year
- 1 – 2 years
- 2 – 4 years
- 4 – 7 years
- 7+ years
Are you interested in finding a new job before or after you move?
- Yes
- No
- Unsure
What are you barriers to employment? (Check all that apply)
- My disability
- A child’s disability
- Full-time student
- A lack of childcare
- Clothing needs
- Lack of education
- Transportation costs
- Lack of housing
- Criminal record
- None of the above
- Other
Which of the following best describes your interest in working:
- Interested and searching for work
- Interested in working, but not currently searching
- Not interested in working
- Unable to work due to a disability
How long has it been since you were last employed?
- Less than a month
- 1 – 3 months
- 3 – 6 months
- 6 – 12 months
- 1 – 2 years
- 2 – 4 years
- 4 – 6 years
- 6 – 8 years
- 8+ years
- I have not yet been employed
What was your position at your last job?
Housing and Utilities
Are you currently committed to a lease?
- Yes
- Yes, month to month
- No
Lease Expiration Date
MM slash DD slash YYYY
Will this be your first time renting as an adult?
- Yes
- No
What type of housing are you currently in?
- Public Housing
- Section 8 Voucher Household
- Private market rental
- BRHP voucher (held by another adult)
- Subsidized development (non-HABC)
What public housing development are you in?
What do you currently pay in rent?
Do you currently pay for your own utilities?
- Yes
- No
How many times have you paid rent on time over the last year? (1 – 12)
How much money do you currently have in savings?
Do you have a past due account with BGE?
- Yes
- No
- Unsure
How much BGE debt do you have?
Do you have a past due account with the Housing Authority of Baltimore City (HABC)?
- Yes
- No
- Unsure
How much HABC debt do you have?
Do you have a past due account with a current or former landlord?
- Yes
- No
- Unsure
How much landlord debt do you have?
Transportation
What is your transportation status?
- I have a vehicle and a license
- I have a license, but not vehicle
- I do not have a license
- I use mobility
Are you physically able to drive?
- Yes
- Yes, but I am not interested in driving
- No
Are you interested in Driver's Education Assistance?
- Yes
- No
What sources of transportation does your family use?
- Public transit (bus/metro/light rail)
- Other household adult’s personal vehicle
- Rides from friends/family
- Taxi/Uber/Lyft
- Mobility
- Other
Are you interested in assistance obtaining a vehicle?
- Yes
- No
Move Priorities
What prompted you to sign up for this program?
What are your top 3 priorities when deciding where to move?
- Safety
- Good schools
- Employment opportunities
- Close to your current employment
- Housing quality
- Near family and/or friends
- Near public transportation
- Near quality medical care
Where would you like to move?

You may include neighborhoods, zip codes, or regional areas of the city.
Do you have any doubts or reservations about moving your family from your current home or neighborhood?
- Distance from/changing medical providers
- Distance from current job
- Distance from family and/or friends
- Changing children’s school(s)
- Transportation
- Other
- None at this time
How are you feeling about your move? (Select all that apply)
- Inspired/Motivated
- Confident/Determined
- Overwhelmed
- Doubtful
- Pessimistic
- Uninterested in the program
- Other
What are you personally motivated to work on? (Check all that apply)
- Improving credit
- Increasing savings
- Obtaining employment or new employment
- Your own educational goals
- Education quality for your children
- Better budgeting
- Identifying your goals
- Other
Do you have a primary care physician or primary medical provider?
- Yes
- No
If you move to a different neighborhood, will you keep seeing the same medical provider(s)?
- Yes
- No
Does your child have a primary care physician or primary medical provider?
- Yes
- No
If you move to a different neighborhood, will your child keep seeing the same medical provider(s)?
- Yes
- No
- No children in the household
How safe are the streets near your home during the day?
- Very safe
- Safe
- Somewhat safe
- Unsafe
- Very unsafe
How safe are the streets near your home during the night?
- Very safe
- Safe
- Somewhat safe
- Unsafe
- Very unsafe

Download Form Complete Online

HCD Pre-Intake Questionnaire, Pregnancy Referral

Healthy Children Demonstration Pre-Intake Questionnaire (Pregnancy Referral 1)

Pre-Intake Questionnaire

Emergency Contact

Household Composition

Household Adult Information

Household Adult 2

Household Child

Household Child 2

Household Child 3

Household Child 4

Household Child 5

Children and School

Household Special Needs

Education and Training

Household Income

Household Assistance

Employment

Housing and Utilities

Transportation

Move Priorities

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