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Victory Life Intake Form
This form helps us get to know you and your situation so we can serve you best. Please answer honestly and completely. Your responses will remain confidential.
Personal Information
First Name
Last Name
Email
Phone Number
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
Year
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Gender
Male
Female
I'd rather not say
Marital Status
Single
Married
Widowed
Separated
Divorced
I'd rather not say
Background
Employment status
employed
unemployed
Any history of addiction, recovery programs, or other struggles
yes
no
if yes, explain
What is your current living situation?
Homeless
Staying with friends/family
In a shelter/program
Renting/own place but at risk of losing it
Other (please explain)
if other, please explain
Needs & Goals
What kind of help are you seeking?
What are your goals?
Emergency Contact
First Name
Last Name
Phone Number
Signature
Type your new text here.
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