1st Time Check InStep 1 of 8 – Contact12%Contact InformationName(Required) First Middle Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Birth Date(Required) Demographic InformationGender(Required)MaleFemaleTransgender F/MTransgender M/FOtherDon’t KnowRefuse to AnswerRace(Required)American Indian/Alasken NativeAsianBlack/African AmericanWhiteNative Hawian/Other Pacific IslanderDon’t KnowRefuse to AnswerEthnicity(Required)LatinoNon-LatinoPrimary Language(Required)EnglishSpanishOtherReligionCatholicProtestantChristianBaptistJewishMormanMuslimHinduBudhistNoneOtherMarital Status(Required)SingleMarriedWidowedSeperatedDivorcedDomestic PartnerCommon LawNumber of People in HouseholdAdults(Required)Children(Required)HistoryDisabled(Required)YesNoExoffender(Required)YesNoCurrentVeteran(Required)YesNoAre You Currently Employed(Required)YesNoIf yes, Full-time or Part-time?(Required)Full-TimePart-TimeCurrent Housing Situation(Required)HomelessEmergency ShelterTransitional HousingRenting a HouseOwn a HouseHow were you referred to BTC?Mental HealthAre you having Suicidal Thoughts?(Required)YesNoAre you currently receiving counseling?(Required)YesNoDo you need substance abuse assistance?(Required)YesNoAre you a survivor of domestic violence?(Required)YesNoAre you a survivor of human trafficking?(Required)YesNoTransportationDo you have access to your own transportation?(Required)YesNoDo you have access to public transportation?(Required)YesNoAre you in need of transportation?(Required)YesNoEmergency AssistanceAre you in need of hygiene items?YesNoAre you in need of food?YesNoAre you in need of clothes?YesNoEmployment Services: Are you interested inWorkforce TrainingTutoringEducationFinancial LiteracyHousehold IncomeWages(Required)Unemployment Benefits(Required)Retirement Benefits(Required)Veteran Benefits(Required)Tanf Benefits(Required)Child Support(Required)Social Security(Required)Workmans Compensation(Required)Pension(Required)Other(Required)
