2026 Comprehensive Intake Form_v2
GENERAL INFORMATION
Today's Date
Staff Member Email
Staff SF ID
Contact Look Up
Contact SF ID
Contact Lookup Birthday
Legal First Name
Last Name
Nickname
Birthdate (MM/DD/YYYY)
CONTACT INFO
Type of Phone
Please select...
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 phone number?
Yes
No
Email
How did you hear about us?
Community event
Flyer
Judge Referral
Pre Trial Docket
Probation/parole officer
Recommended by friend/family
Referred by a different organization
SHOW ME PEACE
Social media
Spire
Website/Google
Other
Other way they heard about us:
Referrer Name
Organization Name
Organization ID
First Name
Last Name
Phone Number
Do you need to add an organization to Salesforce?
Yes
No
Organization Name
Resource Category
BACKGROUND INFORMATION
Are you a registered sex offender and/or been convicted of a sexual offense?
Yes
No
Race
African American/Black
American Indian
Asian
Hawaiian or Other Pacific Islander
Caucasian/White
Biracial
Multiracial
I do not wish to answer
Other
Do you identify as Latino or Hispanic?
Yes
No
What's your primary language?
English
Spanish
Other
Marital Status
Single
Married
Widowed
Separated
Divorced
My significant other lives with me
Common Law
Do you have a disability?
Yes
No
Do not wish to answer
Are you an immigrant, refugee, or asylum seeker?
Yes
No
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
HOUSING, HOUSEHOLD & FINANCES
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
PRIMARY ADDRESS
Street
Apt
City
State
Zip Code
Country
What neighborhood do you live in?
To confirm visit this website:
https://www.stlouis-mo.gov/data/address-search/index.cfm
What shelter?
Please explain.
HOUSING
What type of housing do you have?
Temporary
Transitional Housing Program
Permanent
What is your current living arrangement?
Live in a shelter
Live with family member/friend
Live in a transitional home with support staff
Live in my own apartment/home
Own my home
Do you have a housing subsidy?
Yes
No
Do you have housing in your name?
Yes
No
Have you had an unplanned move in the last 2 years?
Yes
No
How much are you paying for housing?
More than 50% of my income goes to housing
31-50% of my income goes to housing
Less than 31% of my income goes to housing
My housing is paid off
Not paying for housing
HOUSEHOLD & FINANCES
How many people live at your house INCLUDING YOURSELF?
This includes anyone living at the same address/residence/location.
Do you have children?
Yes
No
What type of childcare do you have currently?
Formal - Facility or certified home based provider/Special Progam
Informal - Family or Friend
Not Needed - I do not have children/they are old enough to not need childcare/not responsible
None
Do you have a childcare back up plan for when your primary childcare is unavailable? (For example: when children are off school, sick or when you work 2nd/3rd shift)?
I have a plan in place for them
I don't know/I'll figure it out when I need to
I don't have children/my children are old enough to not need it/I'm not responsible for my children's care
Are you able to work?
Yes
No
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
Current Job Details
Job description
Length of current employment
Less than 3 months
3-5 months
6-12 months
Greater than 12 months
Not applicable (currently unemployed)
Hourly wage
What is your monthly income?
What are your sources of earned income?
Employment
Pension
Side jobs
Other
No source of income
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
Do you have proof of income or benefits?
Yes
No
I don't have income to prove.
What identity documents do you have? (mark all that apply)
Birth certificate
Social security card
Valid driver's license
Invalid driver's license
Non-driver's license
Chauffeur's driver's license
CDL
FINANCIAL EDUCATION
Do you utilize 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?
Less than 10% of monthly income is saved
10% of monthly income saved
50% of monthly income saved
One month or more income saved
What type of loans or debt do you have? (choose all that apply)
PayDay Loans
Title Loans
Credit Card
Utility Bills
Car Loan
Student Loan
Other
None
EDUCATION
Did you receive a high school diploma or equivalent?
No or some high school credits (no diploma or GED)
GED/HiSet
High School Diploma
Do you have any specific job-related skills or certifications?
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
Masters degree
Are you currently attending school?
No
Yes - College
Yes - Technical
Yes - Vocational
TRANSPORTATION
What is your current means of transportation?
No access to transportation
I walk
Public transportation
Private transportation
Do you have a valid driver's license?
Yes
No
Is your mode of transportation affordable?
No it isn't affordable
Yes it is affordable
If you are using private transportation, is your car reliable?
Yes
No
What is the payment status of your car?
Paid off
I am making payments on a loan/lease for this vehicle
Do you have car insurance?
Yes
No
WELLNESS
Does substance use impact your daily life?
Yes
Sometimes
No
Prefer not to answer
Does mental illness impact your daily life?
Yes
Sometimes
No
Prefer not to answer
Have you regularly felt down or nervous?
It's a current challenge for me
I have, but not in the last 6 months
I have, but not in the last year
I haven't regularly felt this way
Have you ever received counseling?
No
I have in the past
I am currently in counseling
I have not needed counseling
Do you have strategies to use when you're feeling down or nervous?
No
Yes, but I have a hard time using them
I use strategies regularly
I don't regularly feel stressed or worn down
Have you been a victim of violence?
Yes
No
Do not wish to answer
Would you be interested in our NHN program?
Yes
No
Notes about referral:
Marking yes will automatically create a referral to Shirla/NHN. There are no further steps.
SELF-EFFICACY
Do you feel your life has meaning and purpose?
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 hard times
I feel equipped to get through hard times with little trouble
Do you use coping skills in difficult times?
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
LEGAL
Do you currently have an open case in St. Louis city?
Yes
No
Do you currently have an open case in St. Louis county?
Yes
No
What charges?
*Beyond jobs does not accept sex offenses or extreme violence.
What is your arrest record?
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
I have never been arrested
What is your incarceration history (sentenced to jail or prison time)?
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
I have never been incarcerated
What is your probation or parole status?
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
I have never been on probation
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
FOLLOW UP
EMERGENCY CONTACT
First Name
Last Name
Relationship
Phone Number
What barriers are you experiencing? (check all that apply)
Cultural barriers/English language learner
Domestic Violence
Education/reading difficulty
Employment/Unemployment
Family Violence
Food Insecurity
Housing/homelessness
Identification
Legal/ex-offender
Low income/receiving government assistance
Medical
Mental Health
Parental support/single parent/lacks childcare
Substance Use
Transportation
Trauma
Additional notes about client:
How was this intake completed?
Phone
In-person
What Program Engagement should this intake connect to?
Resources
Beyond Justice
Beyond Justice P&P
Would you like to make an internal program referral for this client?
Yes
No
INTERNAL REFERRALS
What internal program are you referring the client to?
Program ID
Priority of program contacting participant:
High
Medium
Low
Reason for referral:
Age qualification:
Senior Citizen
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
*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 contacts by a M:STL staff member.
Are you within the age range of 18-50?
Yes
No
Do you currently have consistent & stable housing?
Yes
No
If you have children who require care during the day, do you reliable daytime childcare during program hours?
Yes
No
Not applicable
Do you currently receive any benefits or supplemental income that may affect your work availability or the number of hours you are able to work?
Yes
No
Are you available
9 hours per week
for classes?
Yes
No
Are you available on
Tuesday through Thursday
during any part of the
timeframe
of
10:00 AM–3:30 PM?
(Days & Times sub
ject to change)
Yes
No
If approved for Beyond Jobs, which
class start dates
work best for your schedule?
Please select no more than 2.
May 5
June 2
July 7
August 4
September 1
October 6
November 3
*This person is NOT eligible for the Beyond Jobs Program. PLEASE LET THEM KNOW. Based on their needs please refer them accordingly. They will NOT be contacts by a M:STL staff member.