Beneficiary Intake Form

The first honest answer a caseworker gets often comes from one box: Current Situation, a required open text field where a new client explains, in their own words, why they came in. Around it sit the practical questions, a Services Needed menu with six options running from Food Assistance to Legal Aid, and a Household Size selector that goes from 1 to 6+.

That mix is the point of this beneficiary intake form. It gathers enough to open a case file and match a person to a program without turning a first contact into an interrogation. Completing it takes 6 to 10 minutes, short enough to finish in a waiting room.

Nine fields between a cover page and a thank-you

The form runs a cover page, two content pages, and an ending page, with 9 fields in total. Seven are required: full name, email, address, Household Size, Services Needed, Current Situation, and Referral Source. Phone and Date of Birth stay optional, a small but deliberate choice, since some clients don't have a stable phone number and shouldn't be blocked from submitting because of it.

Referral Source is a single-choice question with five options: Self, Social Worker, Community Organization, Government Agency, or Other. Over a quarter or a year, that one field shows which referral channels actually bring people in, which is exactly the kind of evidence funders like to see.

From a submission to a service match

Every completed intake lands in your Uplup dashboard the moment it's submitted. Per-question breakdowns show demand at a glance: how many households of 5 or more registered this month, how many people selected Housing versus Employment, how many arrived through a Government Agency. When a board report or grant deadline comes around, export the full response set to CSV and work from there.

If your team lives in other tools, webhooks and a Zapier connection can push each new intake to wherever your case management workflow starts, so nobody has to remember to check a second inbox.

Who reaches for this template

Food banks and pantries use it to register new households. Housing and legal aid organizations use it to triage who needs an appointment first. Workforce and education programs use it to route applicants toward the right services. The pattern is the same in each case: one front door, and one consistent record for every person who walks through it.

Make it match your programs before you publish

Every field is editable. Swap the six Services Needed options for the programs you actually run, add an eligibility question, drop Date of Birth if you don't need it, or reword everything for a different language. Your logo and colors replace the defaults, so the page looks like your organization rather than a form builder.

The template is set to traditional mode, a full page of fields at a time, which suits tablet-at-the-front-desk intake. Switch to conversational mode if you'd rather show one question per screen. When it's ready, share a direct link, print a QR code for the waiting area, embed the form on your site, or paste the Uplup plugin's shortcode into a WordPress page. Publishing it requires a Pro plan.