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Client Intake Form
If you are seeking assistance from Team Unify, please complete this form and our team will contact you soon.
Full Name
Email Address
Phone Number
City
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How Did You Hear About Free?
Friend
Resettlement Agency
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Date of Birth
Gender
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Country of Birth
Date you entered the United States
Do You Have Asylum Status?
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If you answered 'Yes" to question before, what date did you get granted asylum? If you answer 'No", please write N/A
If you ansered "No", Have you applied for asylum?
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Do You Have Refugee Status?
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No
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Are You a United States Citizen?
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No
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If you answered "No" to the question before, what is your immigration status and your Alien Number?
What is the Primary Language spoken at HOme?
Do you need an interpreter?
Yes
No
Please list all the people in your family/household (not including self).
Does someone in your household have a car/truck?
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Does someone in your household need help finding a job?
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If you answered yes to the question before, are they authorized to work in the US?
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No
Please list all the people in your family/household who works.
What is the households combined total income?
What is the highest level of education before coming to the US?
No formal schooling
Grades 1-8
Grades 9-12
High School Graduate
Some College, No Degree
Associates Degree
Bachelor's Degree
Master's Degree
Doctorate Degree
Do you or anyone in y our household currently receive public benefits such as food stampes, Medicaid, or TANF fash?
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No
Do you or anyone in your household need help to apply for benefits such as food stamps, Medicaid, or TANF cash?
Yes
No
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