Please complete the questionaire

By completing this form, we will be able to start the process of your intake much quicker, and get the help for you that you need right away. Please allow 10-15 minutes for completing this form.

* indicates required
/ / ( mm / dd / yyyy )
Gender (optional)
Currently or formerly incarcerated? *
/ / ( mm / dd / yyyy )
/ / ( mm / dd / yyyy )
/ / ( mm / dd / yyyy )
Highest education level *
Are you a U.S. citizen?
Do you speak a language other than English?
If so, what language?
Default on student loans/unpaid education expenses
Do you have family willing to help for education?
Do you have children?
Do you have an active parenting partner?
If incarcerated, do you have a home plan?
Do you have drug/alcohol abuse history?
How long have you been clean and/or sober?
How many times have you been in treatment?
Are you currently on any medications?
Have you been hospitalized for mental health?
Does your income cover your expenses?
Race/Ethnicity (optional)
Services you are seeking (check all that apply)
If you prefer to stop in to complete your forms, and speak with someone right away, please check the URC Intake Schedule. .