Win Each Moment- Intake Form Name * First Name Last Name Date of birth Phone (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Are youcurrently on parole or probation? Yes No If yes,pleaseprovide the name and contact information for your officer: * Do you have any pending legal cases? Yes No What challengesare you currently facing? (Check all that apply) Substance abuse Mental health issues Lack of employment Financial difficulties Housing instability Legal or custody issues Other What is your highest level of education? Less than high school High school diploma/GED Some college College degree Are you currently employed? Yes No If yes,what is your current job title? _ * Do you have a resume? Yes No Do you have a bank account? Yes No Are you interested in financial literacy or credit counseling? Yes No Do you have children? Yes No If yes,how many? What is your current relationship with your children? Active and involved Limited involvement No contact Do you need legal support for custody or visitation? Yes No Which services are you most interested in? (Check all that apply) Rehabilitation services (substance abuse, mental health) Credit counseling and financial literacy Home buyer education Job placement assistance Custody and legal support Others What are your short-term goals (next 6 months)? What are your long-term goals (1–5 years)? Do you have access to reliable transportation? Yes No Is there anything else you would like us to know about your situation? Thank you!
