Community Couch Intake

Community Couch Services Intake

Needs Assessment

STEP 1 OF 9

CONTACT DETAILS

First Name *

Last Name *

Email *

Phone

Date of Birth *

STEP 4 OF 9

PRESCREEN QUESTIONS

Do you have any disabilities? *

Yes

No

What form of ID do you have? *

Social Security Card

State Issued ID

Birth Certificate

Other

Please specify the ID you have *

STEP 9 OF 9

PRESCREEN QUESTIONS

IF YOU ARE STAYING IN THE RESIDENCE OF ANOTHER PERSON OR IN A RESIDENCE YOU RENT/OWN have you been told by the person with whom you're staying, or received a court ordered eviction, or landlord indicating you must leave within the next two weeks? *

Yes

No

Include the name and phone number.

Emergency Contact Information

Signature *

Clear

Today's Date *

I certify that my answers are true and complete to the best of my knowledge.

If this intake results in services being offered, I understand that providing false or misleading information in my application or interview may lead to my termination.

Your data will be used to assess needs and connect you to available resources. It may also be shared with our partner agencies (except for questions intended for internal use only) and employers.

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Benefits

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FAQ

Whats the Hiring Process Like?

Step 1: Apply Online

Step 2: Interview

Step 3: Job Offer

Step 4: Background Screening

Step 5: Welcome Aboard