BRHP | RPBV Intake Form

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.
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/Alaskan 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
Email
Home Phone
Cell Phone
Work 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 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 when you move?*
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?*

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
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 1

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)
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

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 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

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
- None of the above

Household Income

Please indicated how much income you receive from the following sources
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
- Childcare assistance
- Transit assistance/mobility
- Utility assistance
- Medicaid/Medicare
- Other
How much do you receive in food stamps?

RPBV Intake Questionnaire

RPBV Pre-Intake Questionnaire

Step 1 of 11

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

RPBV Intake Questionnaire

RPBV Pre-Intake Questionnaire

Step 1 of 11

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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