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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?
Nicole Saunders
Shamon Thomas-Green
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
Complete Online
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