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Phase 1 : Love INC Client Intake Process
Step
1
of
6
16%
Love INC of Brevard
Please be aware that Love INC of Brevard is not an emergency service program as we do not provide money. Our mission is to offer support and resources through our network of local partners to help those in need. This is an in-depth form (it takes most people 20-45 minutes to complete) as our program is a holistic and deeply-relational program. Over 20 years of transforming people's lives we have found that true, lasting change is only possible when an individual opens up their life to us so we can heal the deep underlying issues (not just the symptoms). Our experience has shown us that - most often - what drives people to reach out to Love INC is a symptom of the deeper issue. Yes, we want to treat the symptom, but our program is designed to go much deeper to heal the deepest level of whatever is causing these symptoms in your life. Truthfully, this can be an uncomfortable process. Especially in the beginning as you are learning whether or not you can trust Love INC with your life. We understand that not everyone is desiring or ready for this type of deep, life-transforming work. However, if you know that you need help, and you're willing to do whatever it takes to make a transforming-change in your life, then you are the perfect person to begin your journey with Love INC! We can't wait to see how God is going to make you into all He created for you to be!
I understand that Love INC does not give away cash, and that this is a long-term, deeply-relational, life-transformation program. I am ready to do whatever it takes to make a lasting change in my life!
(Required)
Your Personal Information
Your Name
(Required)
First
Middle
Last
Date of Birth
(Required)
Month
Day
Year
Gender
(Required)
Male
Female
Other Names Known By (Aliases, Maiden Name, etc.)
First
Last
Marital Status
(Required)
Single
Married
Widowed
Common Law / Live-In
Separated
Divorced
I heard about Love INC through:
(Required)
Church
Family / Friend
Google Search
Social Media
Love INC Resource Guide
Another Non-Profit
Local Business
Other
If Other, please be specific:
Name of church, family member, friend or organization who referred you to Love INC:
Preferred Contact Method:
(Required)
Email
Mail
Phone
Text
Cell Phone
(Required)
Home Phone
Your Email Address
(Required)
Ethnicity
(Required)
Hispanic or Latino
Not Hispanic or Latino
Race
(Required)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Do you attend church?
(Required)
Yes, 1x/month
Yes, 2x/month
Yes, 3x/month
Yes, weekly
Yes, Holidays only
No
If yes, what is the name of your church?
Your Household Information
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Partner's Name
(Required)
First
Middle
Last
Other Names Partner Is Known By ( Aliases, Maiden Name, etc.)
First
Last
Partner's Phone
(Required)
Partner's Date of Birth
(Required)
Month
Day
Year
Partner's Age
(Required)
Partner's Gender
Male
Female
Partner's Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Partner's Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
# of Adults In Household
Including you and your partner. Could include grandparents living in the home or other adults living in the home.
# of Children In Household
Household Members
(Required)
Other than yourself and your partner, please enter the number of people currently living in your household.
Household Members
(Required)
Other than yourself and your partner, please list all the people currently living in your household. Please list children first, then other adult members.
First & Last Name
Gender (M/F)
Date of Birth
Age
Custody (Y/N)
Disabled (Y/N)
If Disabled, Please List Disability
Add
Remove
List any children not currently living with you:
First & Last Name
Gender (M/F)
Date of Birth
Age
Do you have custody (Y/N)
Disabled (Y/N)
If Disabled, Please List Disability
Are these children In Touch (IT) or Estranged (E)
Add
Remove
Background Information
Client Status
(Required)
I have never been a Love INC client
I am a returning client
Approx. Date of Last Love INC Request
(Required)
MM slash DD slash YYYY
Have you requested or are you receiving help from anywhere else?
(Required)
No
Yes, I have requested assistance from other organizations and been denied
Yes, I have requested assistance from other organizations and am I am currently waiting on their response
Yes, I have received or am receiving assistance from other organizations
Describe assistance requested or currently receiving:
(Required)
Are you disabled?
(Required)
Yes
No
Approx. Date of Disability
MM slash DD slash YYYY
Are you a Veteran?
(Required)
Yes
No
Have you been arrested or have you had other legal issue?
(Required)
Your answer will not affect our care for you in any way.
Yes
No
If you've been involved in the legal sysem, please provide context.
Current Living Arrangement
(Required)
Homeless
Hotel
I own my home
Rent
Rent to own
Shelter
Staying with friend/family
Transitional Housing
Approx. Date This Living Arrangement Started
MM slash DD slash YYYY
Are you a legal resident?
(Required)
Yes
No
In Process
Do you receive child support?
(Required)
Yes
No
In Process
Do you have health insurance?
(Required)
Yes
No
Is your partner a legal resident?
Yes
No
In Process
I give permission to Love INC to leave a message with
First
Last
Employment
Are you currently Employed?
(Required)
Yes
No, I receive unemployment
No, I do not receive unemployment
Name of Current Employer
Approx. Monthly Take Home Pay
Approx. Monthly Unemployment Pay
Approx. Date Unemployment Began
MM slash DD slash YYYY
Name of Most Recent Employer
Overall Wellbeing Assessment
How would you describe your mental health?
(Required)
1 - Bad: I am constantly overwhelmed, anxious, and/or depressed
2 - Poor: I am mostly overwhelmed, anxious, and/or depressed with occassional good days
3 - OK: I experience as many good days as I experience bad days
4 - Good: I would describe most days as happy, joyful, and enjoyable
5 - Great: The large majority of my days are happy, joyful, and enjoyable
Do you have tools and strategies for coping with anxiety, stress, depression, and/or other poor mental states?
(Required)
Yes I do
No I do not
How would you describe your spiritual health?
(Required)
1 - I do not have any sort of faith
2 - I have some faith in God, but it doesn't impact my day-to-day life
3 - I believe in God and I pray when I need something
4 - I have a strong belief in God, I pray frequently, and I ask him for guidance
5 - My faith in God is the most significant guiding light in my life, I seek to know God, and surrender my life to God
Are you a Christian?
(Required)
Yes
No - I identify with another faith
No - I do not identify with any faith
I'm not sure, I would be interested in talking with someone about Jesus
Which scenario best describes your current transportation.
(Required)
I have my Driver's License and a vehicle that I do not share with anyone
I have my Driver's License and a vehicle that I share with one other person
I have my Driver's License and a vehicle that it sometimes available for me to use
I do not have my Driver's License, but if I did there is a vehicle I could use
I do not have my Driver's License, and there is not a vehicle that I could use even if I obtained my Driver's License
I use public transpotation
My friends and family give me rides whenever needed
I mostly use a ride share app like Lyft or Uber
I mostly walk or ride my bike
How would you rate the reliability of your access to transportation?
(Required)
1 - I have no access to transportation
2 - My access to transportation is very limited
3 - I sometimes have transportation for the things I want/need to do
4 - I often have transportation for the things I want/need to do
5 - I always have transportation for the things I want/need to do
Which scenario best describes your relationship to work
(Required)
I am currently employed and enjoy my work
I am currently employed and dislike my work
I am in between jobs right now, and actively looking for work. My most recent employment ended less than 3 months ago.
I am in between jobs right now, and actively looking for work. My most recent employment ended more than 3 months ago.
I am unemployed and not looking for work
I am unemployed due to a disability
Which scenario best describes your personal finances?
(Required)
1 - I never have enough money to pay all my bills each month
2 - I rarely have enough money to pay all my bills each month
3 - I sometimes have enough money to pay all my bills each month
4 - I often have enough money to pay all my bills each month
5 - I always have enough money to pay all my bills each month
6 - I always have enough money to pay all my bills each month and I save money consistently for unforeseen expenses
Do you have current outstanding credit card debt?
(Required)
Yes
No
Do you own your home?
(Required)
Yes
No
If you do not own your home, would you like to own your home?
Yes, I would like to own my home
No, I do not have a desire to own my own home
How would you rate the stability of your current housing situation?
(Required)
1 - I am contstantly worried about where I will be staying/living next
2 - I am often worried about where I will be staying/living next
3 - I sometimes worry about where I will be staying/living next
4 - I rarely worry about where I will be staying/living next
5 - I never worry about where I will be staying/living next
Could you handle a surprise expense of $300 without asking for help or needing to pick up more work?
(Required)
Yes I could. I have enough money in my accounts to pay a $300 unforeseen bill while also paying all my normal monthly expenses
No I could not.
How would you rate your physical health?
(Required)
1 - I live in constant pain and/or I have a health condition that impacts my ability to
2 - Most days I have pain that negatively affects my quality of life
3 - I have as many good days as I have bad days as it concerns my physical health.
4 - Most days I feel good, and my physical health does not limit my ability to enjoy life
5 - I would describe myself as 90-100% healthy, and my quality of life is enhanced by the way I feel in my body
I would like Love INC to help me with:
(Required)
Dental Concern
Vision Issue
Mental Health Issue
Other Medical Concern
I do not have any medical issues at this time
How would you rate the quality of your social network
(Required)
1 - I do not have any friends or family I can call on
2 - I have a few friends and/or family members that I can call on
3 - I have some friends and/or family I can call on
4 - I have many friends and/or family I can call on
Your Budget : Monthly Income
Child Support
Average monthly income from child support
Employment/Wage
Average monthly income from your job(s)
Family Assistance
Average monthly income from any family assistance
Social Security
Average monthly income from social security payments
Unemployment
Average monthly income from any unemployment program
Spousal Support
Average monthly income from spousal support
Retirement/Pension
Average monthly income from any retirement or pension program
Cash Assistance
Average monthly income from receiving cash from others
Other Income
Average monthly income from something not listed
TOTAL Income: (Auto Populates)
You shouldn't need to fill this in. The total should add up all the previous income categories.
Your Budget: Government Assistance
Disability Insurance (SDI)
Disability SS (SSI)
Monthly
Food Stamps
Monthly
Other grant
Monthly
Subsidized rent amount
Monthly
Veterans Benefit
Monthly
WIC
Monthly
Medicare/Medicaid
Monthly
TOTAL Government Assistance
Monthly
Your Budget: Monthly Expenses
Cable/Internet
Monthly
Car Insurance
Monthly
Car Payment
Monthly
Cigarettes
Monthly
Credit Card Loans
Monthly
Daycare
Monthly
Electricity
Monthly
Food (full amount including food stamps)
Monthly
Gas (for house)
Monthly
Gas (for car)
Monthly
Homeowners Insurance
Monthly
Medical Bills
Monthly
Medical Insurance
Monthly
Mortgage
Monthly
Other Utilities
Monthly
Pay Child Support
Monthly
Phone (Landline/Cell)
Monthly
Property Taxes
Monthly
Rent (Full Amount)
Monthly
Tithe
Monthly
Charitable Giving
Monthly
Education Expenses
Monthly
Clothing
Monthly
Toiletries/Cleaning Products
Monthly
Laundry
Monthly
Alcohol
Monthly
Water
Monthly
Entertainment
Monthly
Subscription Services (Netflix, Disney+, etc...)
Monthly
TOTAL Monthly Expenses
This should auto-populate
Your Needs
What brought you to Love INC today? What can we help you with?
(Required)
Which of the following windows would work for a weekly 15-minute call from your Mentor?
(Required)
Select all that apply. This helps us know how to best accommodate your schedule as we match you with a mentor. The day and times you select should be days and times you are consistently available so we can plan a weekly call with your mentor on this same day every week.
Monday, 6-8pm
Tuesday, 11-2pm
Wednesday, 11-2pm
Thursday, 11-2pm
None of these times work with my schedule
If none of the times work, what time would work for a weekly call with your mentor?
Please list 2-3 different 1-hour block windows.
Important Next Step: Two References!
Thank you for answering these initial questions. Your next step is to have 2 personal references call us on your behalf at 321.253.9542. These can be family or friends that you have known for one year or more. Personal references help us to know you better. Please have them contact us in the next week (7 days). Please check back with us in one week to see if your reference(s) have contacted us. If they have not, please ask a different reference to contact us within the next 7 days. We cannot continue your intake application until we have received your references. If we do not receive them we will close your file. Once your references have spoken to us, we will contact you to complete the remainder of the intake application process when we are available to do so. In the meantime, please contact us with any updates and/or questions.
Call Center Hours:
Monday Evening: 6 PM to 7:45 PM | Tuesday - Thursday: 11 AM to 1:45 PM (If a reference calls us outside of our call center hours, please encourage them to leave a message and we will return their call during our next shift.)
Thank You!
We look forward to being part of your transformation journey! (Don't forget to have your references call us!)
