M:STL Combined Intake & Screening Form
STAFF INFO
STAFF INFO
Staff Member Email
Staff Member SF ID
Date of Screening
CONTACT INFORMATION
Legal First Name
Last Name
Birthdate (MM/DD/YYYY)
Preferred First Name (Do you go by a different name?)
How can we contact you?
Cell
Home
Work
Other
Primary Phone Number
Can we text you at this phone number?
Yes
No
Secondary Phone Number
Can we text you at this secondary number?
Yes
No
Email
If no email, please enter: noemail@gmail.com.
ADDRESS
Which of these applies to you?
I have a primary address
I'm staying with family/friends
I'm currently staying in a shelter
I'm unhoused (not staying anywhere)
I'm not staying anywhere consistently
Other
Street
City
State
Please select...
MO
IL
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
MO, IL, etc.
Zip Code
Please explain your housing situation.
What shelter are you staying at?
What neighborhood do you live in?
Please select...
Not STL City
Address Unconfirmed
Academy
Baden
Benton Park
Benton Park West
Bevo Mill
Botanical Heights
Boulevard Heights
Carondelet
Carr Square
Central West End
Cheltenham
Clayton-Tamm
Clifton Heights
College Hill
Columbia Square
Columbus Square
Compton Heights
Covenant Blu Grand Center
DeBaliviere Place
Downtown
Downtown West
Dutchtown
Ellendale
Fairground
Forest Park Southeast
Fountain Park
Fox Park
Franz Park
Gravois Park
Greater Ville
Hamilton Heights
Hi Pointe
Holly Hills
Hyde Park
JeffVanderLou
Kings Oak
Kingsway East
Kingsway West
Kosciusko
Lafayette Square
LaSalle Park
Lewis Place
Lindenwood Park
Marine Villa
Mark Twain
Mark Twain I-70 Industrial
McKinley Heights
Midtown
Mount Pleasant
Near North Riverfront
North Hampton
North Pointe
North Riverfront
O'Fallon
Old North STL
Patch
Peabody Darst Webbe
Peabody Lasalle
Penrose
Princeton Heights
Riverview
Shaw
Skinker DeBaliviere
Soulard
Southampton
Southwest Garden
St. Louis Hills
St. Louis Place
The Gate
The Hill
The Ville
Tiffany
Tower Grove East
Tower Grove South
Vandeventer
Visitation Park
Walnut Park
Walnut Park East
Walnut Park West
Wells/Goodfellow
West End
Wydown Skinker
To confirm visit this website: https://www.stlouis-mo.gov/data/address-search/index.cfm
BACKGROUND INFORMATION
Race
African American/Black
American Indian
Asian
Hawaiian or Other Pacific Islander
Caucasian/White
Biracial
Multiracial
I do not wish to answer
Other
Other Race
Do you identify as Latino or Hispanic?
Yes
No
Is English your primary language?
Yes
No
What other languages do you speak?
Marital Status
Single
Married
Widowed
Separated
Divorced
My significant other lives with me
Common Law
What is your gender identity?
Male
Female
Non-Binary
Prefer not to say
What is your sexual orientation?
Heterosexual (straight)
Homosexual
Bisexual
Asexual
Identity not listed
Prefer not to disclose
Have you ever served in the military?
Yes, active military (currently)
Yes, reserve military (currently)
Yes, prior service (veteran)
No
Do you have a disability?
Yes
No
Do not wish to answer
Are you deaf or have serious difficulty hearing?
Yes
No
Are you an immigrant, refugee, or asylum seeker?
Yes
No
HEALTH & WELLBEING
Have you ever been diagnosed with a mental illness?
Yes
No
Prefer not to answer
Do you have a history of substance abuse?
Yes
No
Prefer not to answer
What type of insurance do you have?
Medicare
Medicaid
Veterans Administration
Private Health Insurance
No Health Insurance
Have you been a victim of violence?
Yes
No
Do not wish to answer
EDUCATION & EMPLOYMENT
EDUCATION
What is your highest level of education?
No Schooling
No High School
Some High School
High School Graduate
GED or equivalent
Some College
Associates Degree
Bachelors Degree
Masters Degree or Higher
Do you have any specific job-related skills or certifications?
EMPLOYMENT
Are you able to work?
Yes
No
If no, why not?
Retired
Disabled
Other
Please explain:
Have you ever been employed?
Yes
No
Current employment status:
Unemployed
Employed, but inconsistent work history
Employed, but seeking better opportunity
Happily employed
Job details (check all that apply):
Inconsistent work history
Want more hours
Want better pay
Need training
Looking for growth
Location of job
Schedule of job
Career/industry change
Job industry:
Retail
Manufacturing
Food service
Hospitality
Admin
Other
Were you fired, laid off or did you quit? Please explain:
What are your employment needs?
Transitional job - short-term internship to gain work skills and experience
Skilled training
Straight to work - I have 6+ months of recent, consecutive work history, can pass drug test, has employable skillset
No needs at this time
Have you participated in any job readiness programs before?
Yes
No
Please provide details about past job readiness programs:
Why are you interested in joining the Beyond Jobs/Hire St. Louis program?
What are your primary goals for participating in the program?
Are you committed to attending the program classes at least three times a week?
Yes
No
Why not?
Do you have any specific preferences or needs that should be considered in program design? (e.g. scheduling, accommodations)
FINANCES & HOUSEHOLD
HOUSEHOLD
How many people live at your house INCLUDING YOURSELF?
Please select...
1 (only you)
2 (you + 1 other person)
3 (you + 2 other people)
4 (you + 3 other people)
5 (you + 4 other people)
6 (you + 5 other people)
7 (you + 6 other people)
8+ (you + 7 or more other people)
This includes anyone living at the same address/residence/location.
Do you have children?
Yes
No
Are any of your children under 18?
Yes
No
How many of your children are under 18?
FINANCES
What is your monthly income?
What are your sources of earned income?
Employment
Pension
Side jobs
Other
No source of income
Please explain other income source:
Do you have proof of income?
Yes
No
Which public benefits or government assistance do you receive? (mark all that apply)
Cash assistance TANF
Child support
Childcare vouchers
Children's SSDI
Food stamps
Medicaid
MO HealthNet
Section 8
SSDI
SSI
Unemployment benefits
Veterans compensation
Other
None
Please explain other benefits:
What identity documents do you have? (mark all that apply)
Birth certificate
Social security card
Valid driver's license
Non-driver's license
Chauffeur's driver's license
CDL
LEGAL HISTORY
Have you been incarcerated within the past 6 months?
Yes
No
Have you been involved in the justice system in the past 6 months?
Yes
No
This includes probation, parole, released from jail/prison, pending warrants or criminal court cases. This does not include anyone incarcerated in the last 6 months.
Do you currently have an open case in St. Louis city?
Yes
No
Please explain your St. Louis city case:
Do you currently have an open case in St. Louis county?
Yes
No
Please explain your St. Louis county case:
ADDITIONAL INFORMATION
What barriers are you experiencing? (check all that apply)
27+ weeks unemployed
Cultural barriers
Domestic Violence
Employment
English language learner
Ex-offender
Family Violence
Financial
Food Insecurity
Homelessness
Identification
Lacks childcare
Lacks transportation
Legal
Low income
Medical
Mental Health
None apply
Reading difficulty
Receiving government assistance
Single parent
Substance Use
Trauma
Other
Please explain other barriers:
EMERGENCY CONTACT
First Name:
Last Name:
Relationship:
Phone Number:
How did you hear about us?
Community event
Flyer
Probation/parole officer
Recommended by friend/family
Referred by a different organization
SHOW ME PEACE
Social media
Website/Google
Other
Please explain how you heard about us:
REFERRAL SOURCE
If a specific person referred you to Mission: St. Louis, please indicate their first name, last name, and phone number below. Leave blank if unknown.
First Name:
Last Name:
Phone Number:
Would you like to make an internal program referral for this client?
Yes
No
INTERNAL REFERRAL
What program are you referring the client to?
Please select...
Beyond Jobs
Beyond Justice
Enterprise
Hire St. Louis
Minor Home Repair
NHN
Places for People
SHOW ME PEACE
Reason for referral:
MHR Eligibility Questions
Age qualification:
Senior Citizen (60+)
Legally Disabled
Neither
Is lower-moderate income?
Yes
No
Owns their home?
Yes
No
Lives in St. Louis city?
Yes
No
Is up-to-date on property taxes?
Yes
No
Does NOT qualify for MHR
*This person is NOT eligible for the Minor Home Repair Program. PLEASE LET THEM KNOW. Based on their needs please refer them accordingly. They will NOT be contacted by a M:STL staff member.
Enterprise referral
*After completing this form, please make an appointment with Stephanie via this link.
Additional notes about client: