General Intake Form

Do you live in The Colony, TX?*
- Yes
- No
Assistance is currently ONLY available to The Colony, TX residents.

For additional resources in Denton County please go to United Way Denton - COVID-19 Resources.
Client Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
- Female
- Male
Ethnicity
Race
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email*
Next Steps
How did you hear about Next Steps?*
I need help from Next Steps with...*
Please explain*
Have you been helped by Next Steps in the past?*
- Yes
- No
When?
MM slash DD slash YYYY
Felony
Do you have a felony conviction on your record?*
- Yes
- No
If yes, please explain
Safe Place to Live
Do you have a safe place to live?*
- Yes
- No
Where is it?
Please explain*
How much does it cost?
Are you in a contract?
- Yes
- No
Until when?
MM slash DD slash YYYY
Who do you live with?*
Transportation
Do you own a car?*
- Yes
- No
Do you have insurance?
- Yes
- No
Are you legal to drive?*
- Yes
- No
Do you have a current driver's license?*
- Yes
- No
How do you get where you need to go?
Drug Use
Do you now or have you ever abused legal or illegal substances?*
- Yes
- No
When was the last time you used?
MM slash DD slash YYYY
How long have you been sober?
Documentation
Are you missing any vital documents?
ID*
- Yes
- No
Birth certificate*
- Yes
- No
Where were you born?
Driver's license*
- Yes
- No
Social security card*
- Yes
- No
Employment
Employment status*
- Employed Full-Time
- Employed Part-Time
- Self-employed
- Not employed but looking for work
- Not employed and not looking for work
- Homemaker
- Retired
- Student
- Prefer Not to Answer
Where do you work?
When did you start?
MM slash DD slash YYYY
How long do you plan to stay at this job?
What kind of work experience do you have?
Do you have a current resume?*
- Yes
- No
Family/Friend Support
Do you have family/friends that have helped you in the past by giving you a place to stay or helping you with money?*
- Yes
- No
How have they helped?
Food
Do you receive food stamps?*
- Yes
- No
Have you visited a local food pantry?*
- Yes
- No
CAPTCHA

Address
4431 Augusta St
The Colony, TX 75056

Business Hours
Tue – Thur …… 10 am – 2 pm
Case management by appointment

Phone
(972) 445-7770

Email
pam@nextstepstc.org

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Client Information

Next Steps

Felony

Safe Place to Live

Transportation

Drug Use

Documentation

Employment

Family/Friend Support

Food