FSI Preliminary Intake Form

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Email*

How did you hear about us?*

Who at Knowledge Quest Staff told you about us?

Do you have an immediate need/crisis today related to a basic need?*

If you responded yes, please specify the immediate need:

Please specify the other type of immediate support you need.

Are you seeking support/guidance but are not in crisis today?*

If you responded yes, please specify the support/guidance:

Please specify the other type of support you need.

Do you have at least one school age child(ren) (who resides in the home with you)?*

Do you currently have a child(ren) enrolled in Knowledge Quest’s After School Program?*

If you responded yes, please specify (check all that apply):