CPI Form
Survey Type
Survey Type
Please select...
Intake
Quarterly
Intake
Please click "Next Page" to continue to the INTAKE CPI SURVEY.
*If you are supposed to be completing the Quarterly Update Survey, you have the wrong form!
Quarterly Update
Please click "Next Page" to continue to the QUARTERLY UPDATE CPI SURVEY.
*If you are supposed to be completing the Intake CPI Survey, you have the wrong form!
Contact Information
Legal First Name
Last Name
Date of Birth (MM/DD/YYYY)
What is the best number for us to reach you at?
Type of Phone
Cell
Home
Work
Other
Primary Phone Number
Can we text you at this phone number?
Yes
No
Education
Highest School Grade Completed
4th
5th
6th
7th
8th
9th
10th
11th
12th
Did you receive a high school diploma or equivalent?
No or some high school credits (no diploma or GED)
GED/HiSet
High School Diploma
Have you completed any additional educational training?
None
Short-term program (less than 1 month)
Medium-term program (1 month to 2 years)
Long-term program (2 or more years)
Associate degree
Bachelors degree or higher
Are you currently attending school?
No
Yes - College
Yes - Technical
Yes - Vocational
List any active license or certifications you posses.
Employment
Current Employment Status
Unemployed- no work in the last 9 months
Unemployed- Perm, Temp or seasonal work within the last 9 months
Temporary part-time employment/ gig work or contract
Temporary full-time employment
Permanent part-time employment
Permanent full-time employment
Retired with benefits
Retired withOUT benefits
Length of current employment
Less than 3 months
3-6 months
7-12 months
Greater than 12 months
Not applicable (currently unemployed)
Most Recent Job Industry Type
Construction
Education
Healthcare
Manufacturing
Restraurant
Retail
Social service
Other industry
Not applicable
Most Recent Job Hourly Wage
Less than $10
$10 - $12.49
$12.50 - $14.99
$15 - $17.49
$17.50 - $19.99
$20 - $22.49
$22.50 - $24.99
Greater than $25
Not applicable (I have never been employed)
Most Recent Job Hours Worked per Week (type a 1-2 digit number, NOT a range)
Finances
Do you use a budget?
Never
Inconsistently
Consistently
My budget balances every month
How much do you save monthly?
I don't save
Inconsistently save
Consistently saving 2% of my income
Consistently saving 5% of my income
How much money do you have saved?
None
10% of one month's income saved
50% of one month's income saved
1 month or more income saved
Title Loans
Utility Loans
Auto Loans
Pay Day Loans
College Debt
Credit Card Debt
What type of debt do you have?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Childcare
Do you have a childcare back up plan for when your primary childcare is unavailable?
I do not have children
I have a plan in place for them or they are old enough they don't need childcare
I don't have a plan in place for them
Do you currently have childcare for your children?
I do not have children
I have permanent childcare arrangements (i.e. a daycare I use weekly)
I have informal childcare arrangements (i.e. a family member I can leave my child with occasionally)
I do not have childcare arrangements
My children are old enough that they don't need childcare
Housing
What type of housing do you have?
Homeless
Transitional shelter
Temporarily stable (staying with family/friends, or staying in supportive housing)
Permanent
Do you have a rental subsidy?
Yes
No
Do you own your home?
Yes
No
Is your current housing in your name?
Yes
No
Have you had an unplanned move in the last 2 years?
Yes
No
How much of your income is going to rent or mortgage?
Not currently paying rent/mortgage
More than 50% of my income
30% or less of my income
31% - 50% of my income
Transportation
What is your current means of transportation?
No access to transportation
Rely on public transportation
Access to motor vehicle / private transportation
Is your mode of transportation affordable?
Yes it is affordable (spends less than 10% of income on transportation)
No it is not affordable (spends more than 10% of income on transportation)
Do you have a valid driver's license?
Yes
No
If you have a car, is it reliable?
Yes
No
Not applicable, I do not have a car
If you own a car, what is the payment status of your car?
Paid off
I'm making payments on a loan/lease for the vehicle
Not applicable, I do not own a car
If you own a car, do you have valid auto insurance
?
Yes
No
Not applicable, I do not own a car
Healthcare
Health Insurance
Dental Insurance
Eye Doctor Insurance
What forms of insurance do you have?
Yes
No
Yes
No
Yes
No
Primary care doctor
Dentist
Eye Doctor
Which of the following providers do you have access to?
Yes
No
Yes
No
Yes
No
Which of the following have you utilized within the past year?
Yes
No
Yes
No
Yes
No
If "None", why haven't you utilized?
Too expensive
Don't have a relationship with a doctor
Don't have time
Don't have transportation
Other
Have you ever been diagnosed with a mental illness?
Yes
No
Are you experiencing symptoms or complications?
Currently experiencing
None in the last 6 months
None in the last year
Are you currently receiving treatment for mental illness or have you received treatment in the past?
I have never accessed treatment
Have received treatment in the past
Currently receiving treatment
No treatment required
What is your current use of drugs and/or alcohol?
I currently struggle with substance abuse (use of illegal substances, use too much/often of legal substances)
I do not struggle with substance abuse
Describe your current use of substances.
Current challenge
None in the last 6 months
None in the last year
Are you receiving treatment for substance use?
I have never received treatment (but have struggled with substance abuse)
I have received treatment in the past but not currently
I am currently receiving treatment
No treatment is required (I'm not abusing substances)
Social Support
Friends
Family
Co-workers
Neighbors
Faith Community
What forms of social support do you have?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
How often do you provide social support to others?
Never
Weekly
Monthly
Quarterly
Annually
Legal
Do you have any felonies on your record (including SIS)?
Yes
No
If you have any felonies on your record, please describe (
We are asking so we can know how this may impact current and future job placements. Having a felony does not prevent you from receiving services or accessing job opportunities.).
What is your arrest record?
I have never been arrested
I have been arrested in the last 6 months for a new charge
I have been arrested in the last 12 months for a new charge
I have been arrested in the last 12 months for a situation that happened over a year ago
My last arrest was over a year ago
Approximate date of last arrest
Use the calendar to select an approximate date
What is your incarceration history (sentenced to jail or prison time)?
I have never been incarcerated
I have been incarcerated in the last 6 months
I have been incarcerated in the last 12 months
I have been incarcerated over a year ago
Approximate date of last jail/prison entry
Use the calendar to select an approximate date
What is your probation or parole status?
I have never been on probation
I am on probation/parole and non-compliant
I am on probation/parole and compliant
I am not on probation/parole or have not been in over a year
If you currently have legal fees are they affordable?
I cannot afford to pay my current legal fees
I can pay my current legal fees, but do not have money for rent, food or other essentials
I can pay my current legal fees, as well as rent, food and other essentials, but am living paycheck to paycheck
I can pay my current legal fees as well as afford rent, food and other essentials and I still have the ability to save money monthly
I do not have any legal fees
Number of current legal issues (includes traffic tickets, child support, charges, etc.)
7 or more
5-6
3-4
1-2
0
Are you currently dealing with any of the following legal issues?
Active Warrant
Suspended/Revoked Driver's License
Traffic/Municipal Court Matters
Child Support Modification
Debt Collection/Garnishments
Housing/Evictions/Living Condition Issues
Social Security Disability
Pending Felony/Misdemeanor Criminal Charges
Expungement of Prior Criminal Conviction
Immigration
Other
None
Please explain other legal issues
Self Efficacy
How do you view your purpose in life?
I don't care if my life has a purpose or value
I am unsure as to whether my life has a purpose or value
I am actively seeking a sense of purpose and value in my life
I feel that I know my purpose and recognize my life's value fully
How much hope do you have in the world?
I have no hope in the world being good
I want to have hope that the world can be good, but do not yet
I have hope in the world being good
How easy is it for you to persevere through struggles?
I feel like it's pointless and impossible to try to bounce back after hard times
I tend to take a long time to bounce back after hard times
I can usually bounce back after difficult times
I feel equipped to get through difficult times with little trouble
Do you utilize coping skills in times of adversity?
When something bad happens, I shut down. I do not have control over my emotional response or actions
When something bad happens, I have a few coping mechanisms I utilize to handle my emotions, but they don't always work
When something bad happens, I have a series of people and activities I rely on to help me cope with difficult emotions
How would you describe your decision making?
I'm making decision in survival mode with limited options
I make decisions to solve an immediate need, but don't always think about the long-term consequences
I'm making decisions with long-term impact in mind, and I view these decisions as what's best for myself, my family and my community
How would you describe your belief in yourself?
I do not believe I have the power to fully change my life- things are just out of my control
I want to believe I have the power to change my circumstances but I still feel powerless most of the time
I feel I have power over some areas of my life but not all
I believe I have full power to control my circumstances- even when times are hard I have the ability to make a change
Click
Previous Page
if you would like to review your answers. When you are finished, please click
Submit
.
Contact Information