Intake Application - BetterLife Foundation Co

SECTION 1: Basic Information

Please provide your basic information below.

Email

First Name

Last Name

Preferred Name

Date of Birth

Age

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone Number (Mobile Preferred)

I consent to receive SMS messages from this organization.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Relationship

Emergency Contact Phone

SECTION 2: How Did You Hear About Us?

Tell us how you heard about us .

How did you find us?

Other (please specify)

Name of Person or Organization Who Referred You?

SECTION 3: 5-Question Quiz (Self Perception)

Tell us a little about yourself (quick questions).

Q1. Which sounds more like you?

Cooperative / Supportive (you like to help, listen, and work with others)

Take Charge (you like to lead, decide, and be in control)

Q2. Which sounds more like you?

Reserved (quiet, private, keep to yourself)

Outgoing (talkative, social, enjoy being around people)

Q3. Which sounds more like you?

Fast-Paced (move quickly, like things done now)

Patient (take your time, steady, don’t rush)

Q4. Which sounds more like you?

Spontaneous (go with the flow, decide in the moment)

Planned (like structure, think ahead, follow a plan)

Q5. Which sounds more like you?

Skeptical (question things, need proof first)

Trusting (believe others easily, open to people)

SECTION 4: Program Interest & Service Selection

All individuals must begin with Behavioral Insight & Personal Development. This is the required starting point before accessing any additional services. Please select the primary and optional programs you are interested in.

Important: A “Who Am I” full assessment is required before any services can begin.

Required Service

Whole-Life Behavior Reset Workshop

Primary Service of Interest

Optional Services of Interest

Community Practitioner & Peer Support Training

Life Enrichment & Research Initiatives

Review what each service includes here —> https://yourbetterlife.org/#programs

SECTION 5: Current Situation & Needs

Tell us about your current situation & needs.

What best describes your current situation?

Other Current Situation (Explain)

What are the top 1–2 areas you want support in right now?

Briefly describe any other challenges you are currently facing that you would like support with.

SECTION 6: Income & Eligibility (Sliding Scale / Free Services)

This information is used only to determine eligibility for free or reduced-cost services. Your responses will remain confidential and will not impact your ability to receive support.

Current Employment Status

Other Employment (Explain)

Estimated Monthly Household Income

Number of People in Household

• Are you currently receiving any of the following? (select all that apply)

Are you able to contribute toward program services if required?

I understand that I may be asked to provide documentation to verify income or eligibility for free or reduced-cost services.

SECTION 7: “Who Am I” Full Assessment Requirement

All participants are required to complete a behavioral assessment as the first step in the program. This assessment helps us understand how you make decisions, communicate, and respond to challenges so we can provide the most effective support.

Have you previously completed the Who Am I or another behavioral assessment with our organization?

If yes, when did you complete it?

I understand that I must complete the “Who Am I” full assessment before receiving services.

SECTION 8: Availability & Participation

All participants are required to complete a behavioral assessment as the first step in the program. This assessment helps us understand how you make decisions, communicate, and respond to challenges so we can provide the most effective support.

Available Days for Participation

Preferred Meeting Format

If multiple sessions are required, are you able to attend the scheduled sessions consistently?

Would you like to schedule your first session now?

SECTION 9: Consent & Communication

Some description about this section

Consent to Contact
I consent to being contacted by BetterLife Foundation Co via phone, text, or email regarding services and program updates.

SMS Consent
I understand that I can text the main number for support and may receive responses via text.

Data Use Consent
I understand that my information will be used to provide services and may be used in a de-identified format for program improvement or research purposes.

SECTION 10: SIGNATURE

Sign your application by typing your Full Legal Name (as provided on your ID, birth certificate, social security card, or passport).

First Name

Middle Name

Last Name

Enter today’s date

Do THIS Before You Submit

Find your Talent ID # right after this section and PLEASE write down the entire Talent ID # which starts with BLF or at least the last 5 numbers/letters.

You will need this number to contact us and ask questions about your application and/or account.

Talent ID (Write this down. Do NOT Change)