Baltimore Regional Housing Partnership | Pre-Intake Questionnaire

Pre-Intake Questionnaire

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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 move barriers will be and how we can support you along the way.

Which BRHP counselor sent you this questionnaire to complete?*

Name*

First Last

Gender?

What are your pronouns? (select all that apply)

If your pronouns are different than those listed above, what are they?*

What is your race(s)?

White

Black/African American

American Indian/Alaska Native

Asian

Native Hawaiian/Other Pacific Islander

What is your ethnicity?

Hispanic or Latino

Non-Hispanic or Latino

Address*

Street Address Address Line 2 City ZIP Code

Home Phone

Cell Phone

Work Phone

Do you have communication accommodation needs?*

Yes

Do you need to attend workshops offered at special times?*

Yes, evenings

Yes, weekends

Emergency Contact Information

Please fill in the following information for 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

How many children will be in your household?

Household Adult 1

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

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, custody belongs to another household adult

Do all of your school-aged children receive free or reduced price lunch?

Yes

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

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

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 your 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

If you're enrolled in an educational program, what institution?

Are you interested in making further progress with your education?

Yes

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?

Do you have a bank account?

Yes

No, but interested in starting one

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

Other

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

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

If you are unemployed and currently searching for work, what field would you like to work in?

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

Lease Expiration Date

MM slash DD slash YYYY

Will this be your first time renting as an adult?

Yes

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)

Other

What public housing development are you in?

What do you currently pay in rent?

Do you currently pay for your own utilities?

Yes

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

Unsure

How much BGE debt do you have?

Do you have a past due account with the Housing Authority of Baltimore City (HABC)?

Yes

Unsure

How much HABC debt do you have?

Do you have a past due account with a current or former landlord?

Yes

Unsure

How much landlord debt do you have?

What questions do you have about renting?

What (if anything) Do you dislike about your current housing?

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

Are you interested in Driver's Education Assistance?

Yes

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

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

What counties are you interested in moving to? (select all of interest)

Anne Arundel County

Baltimore City

Baltimore County

Carroll County

Harford County

Howard County

Do you have any doubts or reservations about moving your family out of the city?

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

Pre-Intake Questionnaire

Pre-Intake Questionnaire

Emergency Contact Information

Household Composition

Household Adult 1

Household Adult 2

Household Child 1

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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