Intake Paperwork – PACE Client Services Intake

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Unique ID

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Date of Submission

MM slash DD slash YYYY

Client

Your Information

Name*

First Middle Last

Suffix*

None Apply

III

Date of Birth*

MM slash DD slash YYYY

Age*

Social Security Number

Address*

Street Address Address Line 2 City State ZIP Code

County*

Cell Phone

Home Phone

Work Phone

Income Range*

Under $10,000

$10,001 to $15,000

$15,001 to $20,000

$20,001 to $25,000

$25,001 to $30,000

$30,001 to $35,000

$35,001 to $40,000

$40,001 to $45,000

$45,001 to $50,000

$50,000 & up

Gender*

Female

Transgender female

Male

Transgender male

Non-binary

Other

Pronouns*

She/Her/Hers

He/Him/His

They/Them/Theirs

Race*

African American/Black

American Indian/Alaskan Native

Asian

Bi-racial

Caucasian/White

Hawaiian/Pacific Islander

Multi-Racial

Other

Ethnicity*

Hispanic

Non-Hispanic

Marital Status*

Common Law

Divorced

Domestic Partnership

Married, living separately

Married, living together

Separated

Single (never married)

Widowed

Military Status*

Active Duty

Never Served

Spouse of Active Duty Member

Spouse of Veteran

Veteran

Primary Language*

English

Spanish

Arabic

Chinese

Polish

Other

Emergency Contact

Name

First Last

Relationship*

Spouse

Son/daughter

Parent

Other relative

Case worker

Friend

Other

Phone*

Supportive Information

Primary Interest at Program Entry*

Education/Training

Digital Literacy/Computer Instruction

Financial Education/Counseling

Income Supports/Public Benefits

Job Placement/Career Development

Other

Health Insurance Status*

Insured through a government program

No insurance at all

Private insurance through a household member's employer

Private insurance NOT through a household member's employer

Highest Grade Completed*

No High School Diploma

GED/HSE

High School Diploma

Some College

Associate’s Degree

Bachelor’s Degree

Master’s Degree

Doctoral Degree

Are you currently working?*

Yes

Employment Status

Part-time (less than 35 hours per week)

Full-time (35 hours or more per week)

Unemployed & seeking employment

Not in the workforce (homemaker, retired, disabled)

Other

Is your current job also your longest job?*

Yes

Was your previous job your longest job?*

Yes

Vocational Training/Bridge Program History*

No Vocational Training/Bridge Program History

Some Vocational Training/Bridge Program(s) History

Completed Vocational Training/Bridge Program(s)

Are you in school or a training program?*

Yes

Do you have a valid driver’s license?*

Yes

Do you have a valid CDL driver’s license?*

Yes

Do you have a valid chauffeur’s license?*

Yes

In the past 12 months, number of full months worked*

Please enter a number from 0 to 12.

For the past 12 months, your earned income (after tax, this includes SS and disability):*

For the past 12 months, your gross household income:*

Do you receive SSI/SSDI?*

Yes

Including yourself, how many people live in your household?*

Please enter a number greater than or equal to 1.

Do you have children ages 0 – 17?*

Yes

How many children ages 0 – 17?*

Please enter a number greater than or equal to 1.

Child 1: Date of Birth*

MM slash DD slash YYYY

Child 2: Date of Birth*

MM slash DD slash YYYY

Child 3: Date of Birth*

MM slash DD slash YYYY

Child 4: Date of Birth*

MM slash DD slash YYYY

Child 5: Date of Birth*

MM slash DD slash YYYY

Child 6: Date of Birth*

MM slash DD slash YYYY

Child 7: Date of Birth*

MM slash DD slash YYYY

Child 8: Date of Birth*

MM slash DD slash YYYY

Child 9: Date of Birth*

MM slash DD slash YYYY

Do you have a relationship with your children?*

Yes

Are you interested in improving or strengthening a relationship with your children?*

Yes

Do you owe child support?*

Yes

Do you currently pay child support?*

Yes

Do you have a physical or mental disability?*

Yes

Criminal Convictions*

No Convictions

Convicted of Felony/Felonies

Convicted of Misdemeanor(s) only

Don't know

Select the level of your most recent felony conviction.*

F 1

F 2

F 3

F 4

F 5

F 6

Are you on probation?*

Yes

Are you on federal probation?*

Yes

Are you on parole?*

Yes

Are you on home detention?*

Yes

Are you in a work release?*

Yes

Officer or Case Manager Name

First Last

Officer or Case Manager Phone Number

Do you currently have charges pending?*

Yes

In what county are your charges pending?*

Boone

Hamilton

Hancock

Hendricks

Johnson

Madison

Marion

Morgan

Shelby

Other

When were you released from prison?*

Never been to prison

Currently incarcerated

Less than 30 days

1 - 3 months

4 - 6 months

7 months - 1 year

More than 1 - 3 years

More than 3 - 5 years

More than 5 - 10 years

More than 10 years

Which describes your current living situation?*

House or apartment owned by you or a family member

House or apartment rented by you or a family member – subsidized (Low income, Section 8 housing)

Housing with work release, half-way house, recovery/sober living programs

House or apartment rented by you or a family member – unsubsidized

Household stays in a house or apartment for free

Household is homeless (without a roof) or staying in a shelter

What kind of assistance do you need?*

Birth Certificate

Employment

Food or Clothing

Housing Navigation Assistance

State ID

Transportation

Free HIV Testing

Substance Use Treatment/Support

Financial Literacy/Budgeting

Parenting Classes

Mental Health Support/Treatment

Educational Training

Income Supports/Public Supports (SNAP, SSDI, etc)

Peer Recovery Coaching

MRT (Moral Reconation Therapy)

Other

What other assistance do you need?

Do you need assistance with substance use?*

Yes

Are you pre-release?*

Yes

Are you currently incarcerated?*

Yes

(i.e. Marion County Jail, VOA, Duvall, Craine House etc.)

What is your expected release date?*

MM slash DD slash YYYY