Beneficiary Intake Form

Beneficiary Intake Form — Form Fields

This nonprofit template includes 9 fields across 2 pages. Collect information from program beneficiaries for enrollment and needs assessment. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Date of Birth (text, required)
• Phone Number (text, required)
• Email Address (email, optional)
• Address (text, required)
• Household Size (number, required) — Total number of people in your household.
• Services Needed (checkboxes, required) — options: Food Assistance, Housing Support, Job Training, Healthcare, Childcare, Legal Aid, Transportation — Select all that apply.
• How Did You Hear About Us? (dropdown selection, optional) — options: Referral from Another Agency, Community Event, Word of Mouth, Social Media, Other
• Additional Information (long text, optional)