Intake Form

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Name* This field is required.
First Name
Last Name
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Phone Number
Please enter a valid phone number.
3
Email
example@example.com
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Zip Code
Please Select
Please Select
21208
21215
21216
21217
21223
21224
21225
21227
21228
21229
21230
Other
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Birthdate* This field is required.Help us customize the resources to meet your needs by sharing your age.
Date
Year
Month
Day
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TODAY'S VISIT* This field is required.What are you here today for?
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Gender* This field is required.
Please Select
Please Select
Male
Female
Other
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Race* This field is required.
Please Select
Please Select
Caucasian
African American
Hispanic
Asian
Other
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Marital Status* This field is required.
Please Select
Please Select
Married
Single
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Household* This field is required.How many people in the household (including you)?
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How Many Children?Under the age of 18 years old
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CHILDRENList Children Names and Ages Below:
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1) FOODSelect what type of food product or service do you need (NOTE Delivered meals is currently full. If you are housebound in 21223, 21217, 21216 or 21230 please call 443-860-6997‬)
Produce (Fruits & Vegetable)
Proteins (Meats & Dairy)
Grains (Bread, Pasta & Rice)
Self Stable Pantry Goods (Canned & Boxed food)
Delivered Meals
Community Event Meals
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2) CLOTHING
Adult
Youth
Baby
Career
Formal/Prom
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3) BABY & CHILDRENPlease CHECK ALL NEEDS THAT apply and we will connect you with someone to help. Make sure we have your contact information.
Diapers
Formula
Wipes
Equipment
Clothing
School Supplies
Parent Support/Classes
Childcare
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4) DOCUMENTSDo you need help to obtain any of the following documents?
Valid Identification
Social Security Card
Birth Certificate
Immigration/Citizenship
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5) BENEFITSDo you need any of the following social service benefits?
SNAP (Supplemental Nutrition Assistance Program)
TDAP (The Temporary Disability Assistance Program) cash benefits to eligible disabled individuals.
SSI (Supplemental Security Income) monthly benefits for people with limited income
CCS (Child Care Scholarship)
TCA (Temporary Cash Assistance) cash assistance to families with dependent children
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6) HOUSINGAre you in need of housing assistance or more information on any of the following programs?
Shelter
Eviction Prevention
Security Deposit Assistance
Housing Programs (Section-8, HCV, HUD, FSS)
Legal Resources For Renters
Other
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7) UTILITIESHave you received a turn off notice for the following utilities and need assistance paying your bill?
Energy Assistance
Water Assistance
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8) TECHNOLOGYDo you need any of the following communication?
Mobile Phone
Access to the Internet
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9) TRANSPORTATIONWhat do you need to help you get around...
Bus Tokens/Monthly Pass
Learners Permit
Car
Drivers License
Driving School
Other
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10) HEALTHCARESensitive Information Authorization: By checking the box(es) below, I understand and agree that the sensitive information in this section may be used and shared by UEmpower of Maryland, Inc., The Food Project, its Resource Navigator, and appropriate service partners only as reasonably necessary to assess my needs, make referrals, coordinate services, and connect me with care and support.
Doctor
Health Insurance
Medicaid
Dental/Dentures
Medicare (65 and older)
Vision
Other
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11) LEGALSensitive Information Authorization: By checking the box(es) below, I understand and agree that the sensitive information in this section may be used and shared by UEmpower of Maryland, Inc., The Food Project, its Resource Navigator, and appropriate service partners only as reasonably necessary to assess my needs, make referrals, coordinate services, and connect me with care and support.
Child Support Case
Open Criminal Case
Parole or Probation
Immigration
Criminal Pardon
Expungement
Re-Entry Services
Other
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12) THERAPYSensitive Information Authorization: By checking the box(es) below, I understand and agree that the sensitive information in this section may be used and shared by UEmpower of Maryland, Inc., The Food Project, its Resource Navigator, and appropriate service partners only as reasonably necessary to assess my needs, make referrals, coordinate services, and connect me with care and support.
Mental Health Counseling
Substance Abuse Treatment
Medication Management
PRP (building coping & life skills)
Other
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13) SUPPORTNeed emotional or crisis support? Call or text 988, 24/7. If you or someone else is in immediate danger or having a medical emergency, call 911. Need peer support? Call 410.357.7337 (PEER).
Interested in the Safe Harbor Women’s Drop-In Center
Interested in Peer Support at the Recovery Cafe Baltimore
Mentoring
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14) EDUCATIONAre you interesting in the following classes offered at The Food Project?
Food: Culinary/Hospitality
Health: Nutrition & Fitness
Food: ServSafe Certification
Health: CNA/Medical Training
Workforce Development
Health: CPR Certification
Youth Programming
Construction Trades
Entrepreneurship/Leadership
Finance
Continued Education/GED
English Classes
Other
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13) SafetyPlease CHECK ALL THAT APPLY and we will connect you with someone to help. Make sure we have your contact information.
I DO NOT feel safe
I DO PARTICIPATE in risky behavior
I HAVE exchanged sexual acts for money, shelter, drugs, food, or any other basic needs
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Comments
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