Client Intake Assessment Form :

Person Referring
Referral Contacts
Demographic Information
  • Client Last Name :
  • Client First Name :
  • Client Middle Name :
  • Family Suffix :
  • Date of Birth :
  • Age : N/A
  • Gender :
  • Race :
  • Ethnicity :
  • Primary language :
  • Language Access Requested :
  • Special Needs : TTY     Interpreter
Contact Information
  • Street :
  • City :
  • State :
  • ZIP :
  • Telephone :
  • Email :
Education and Employment
  • Employment Status :
  • Annaul Income :
  • Do you have work experience within the past 2 years?   Yes   No
  • If no, previously with whom  
  • Why did the agency deny / discharge?
    •
  • Do you have access to a computer or tablet?   Yes   No
  • If no, explain :
    •
  • Do you have access to a reliable internet connection and/or wifi?   Yes   No
  • Please explain :
    •
  • Are you willing to take a urine drug test?   Yes   No
  • If No, explain :
    •
  • Have you completed secondary education past high school?   Yes   No
  • If yes, where?
    •
  • Have you completed any vocational training?   Yes   No
  • If yes, vocational training programs?  
  • Is the client willing to receive services?   Yes   No
  • If no, are services court ordered?   Yes  No
  • Is there any additional information you would like to share? :
  • In what way would you like this program to assist you? :
  • Do you have any individuals you would like to refer to this program? If so, please provide their full name, email and/or phone number.
Additional Information
Are you a DC resident?          Yes    No         
Are you a veteran?          Yes    No         
Were you ever convicted of a felony or previously incarcerated?          Yes    No         
Have you been vaccinated?          Yes    No         
Do you need Vital Documentation? (Check all that apply)          Valid I.D.    Valid Driver's License    Birth Certificate    Social Security Card   
Do you need Social Services? (Check all that apply)          Housing assistance    Food    Recreational (Mentoring, After School, etc)    Child Care    Public Transportation
-           Clothing    Home Aid    Independent Living    History of Substance Abuse    Medical Assistance (Health, Dental, Medication Assistance)
-           Mental Health (Inpatient/Psychological Treatment, etc)    Income    Life Skills    Health Care Coverage    Community Involvement
-           Family/Social Relation    Community Involvement    Legal    Disabilities    Parenting Skills
-           Children's Education    Adult Education    Credit Score    Other: If checked fill in the next line.   
Other Services Needed         
What employment services are you seeking, if any.(Check all that apply)          Job    Job training/development    Other: If checked fill in the next line.      
Other employment services         
How did you learn about this program?:          Friend/family    CARP Program staff    Online/Web    Social Media    Flyer    Walk-in    Government Agency/Institution/Organization    Government Agency/Institution/Organization: If checked fill in the next line
Other