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Client Intake Form
If you are seeking assistance from Female Refugee Education Empowerment (F.R.E.E.), please complete this form and our team will contact you soon.
Full Name
Email Address
Phone Number
City
State
How Did You Hear About Free?
Friend
Resettlement Agency
Family
Social Media
Other
Date of Birth
Gender
Male
Female
Other
Country of Birth
Date you entered the United States
Do You Have Asylum Status?
Yes
No
Unsure
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?
Yes
No
Unsure
Do You Have Refugee Status?
Yes
No
Unsure
Are You a United States Citizen?
Yes
No
Unsure
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?
Yes
No
Does someone in your household need help finding a job?
Yes
No
If you answered yes to the question before, are they authorized to work in the US?
Yes
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?
Yes
No
Do you or anyone in your household need help to apply for benefits such as food stamps, Medicaid, or TANF cash?
Yes
No
F.R.E.E. will schedule a time for interview with a member of our staff. What days and times are you available for an interview? Select all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
The interview may take as much as an hour to complete. What time of day works best for you to have an interview?
Morning
Afternoon
Submit
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