You must never be fearful about what you are doing when it is right.” – Rosa Parks, civil rights activist

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ICIRR Intake Form

Programs (Pick a Program) * Required

IFRP (Case Management)

IFRP (Info & Referral)

IFRP (Outreach))

NAI (Civics)

NAI (Outeach)

Basic Info of Primary Contact

First

Middle

Last

Intake Staff

Date Entered into the USA

Citizenship Status

Gender

Male

Female

Rather Not Say

Social Security Number

Date of Birth * required

Date of Intake * required

Health Insurance

Preffered Language

Country of Origin

Refugee?

Address Main

City

Zip

County

Home Phone

Cell Phone

Number of Adults

Number of Kids

How you heard about IFRP / NAI

Monthly Income

Income Source

Povery Level

IDHS Case Number

FCRC Office

IDHS Case Worker

Education Level

Education Level Non-US

Employment Status

Taken / Takig ESL

Job

Taken / Taking Voc ed*

Employer

Picture ID Provided

Yes

Languages

English

Speaking

Reading

Writing

Primary

Speaking

Reading

Writing

Other Language

Speaking

Reading

Writing

Barriers

Date * required

Date

Barrier to Accessing Servies

Case Management

Date * required

Goal

How to Acheive

Goal

How to Acheive

Date

Goal

How to Acheive

Type of Goals

Family Members

First

Middle

Last

Relation to Primary

SS (NotRequired)

English

Date Entered into the USA

Gender

Male

Female

Rather Not Say

Speaing English

Reading Eglish

Citizenship Status

Date of Birth

Writing Eglish

Primary

Speaking Primry

Reading Primary

Writing Eglish

Speaking Other

Reading Other

Writing Other

Other

Education Level

Taken / Taking ESL

Non-USA Education Level

Taken / Takng VOC ed*

Employment Status

Job

Employer

Family Members 2

First

Middle

Last

Relation to Primary

Date Entered into the USA

Citizenship Status

SS (NotRequired)

English

Primary

Other

Education Level

Taken / Taking ESL

Gender

Male

Female

Rather Not Say

Speaking Eglish

Speaking Primry

Speaking Other

Reading Eglish

Reading Primary

Reading Other

Non-USA Education LEvel

Taken / Takng VOC ed*

Date of Birth

Writing English

Writing Eglish

Writing Other

Employment Status

Job

Employer

Family Members 3

First

Middle

Last

Relation to Primary

SS (NotRequired)

English

Primary

Date Entered into the USA

Gender

Male

Female

Rather Not Say

Speaking Eglish

Speaking Primry

Reading Eglish

Reading Primary

Citizenship Status

Date of Birth

Writing Eglish

Speaking Other

Reading Other

Writing Other

Other

Education Level

Taken / Taking ESL

Non-USA Education Level

Taken / Takng VOC ed*

Employment Status

Job

Employer

NAI ONLY

Services / Referral (NAI)

Follow Up (NAI)

Actions Taken (NAI)

This section is for NAI Use Only

Client Notes

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Last name

Email*

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Contact Us

We’d love to hear from you! If you have any questions, comments, or feedback, please don’t hesitate to reach out. You can fill out our contact form, email us at qcair@qcair.org, or call us at (563) 594-0854. Our team is here to assist you and will get back to you as soon as possible. Thank you for your interest!

First name

Last name

Phone

Long answer

ADDRESS

4709 44th St Suite 4, Rock Island, IL 61201

Facebook

PHONE

(563) 594-0854.

EMAIL

qcair@qcair.org

Instagram

YouTube

Staff Resources

Media
Kit

QCAIR 4709 44th Suite 4, Street Rock Island, IL 61201 | 563-594-0854

The Quad Cities Alliance for Immigrants & Refugees (QCAIR Inc.) is a 501(c)(3) nonprofit organization founded in 2012 to support immigrants, refugees, and their families.

If you would like to Volunteer Follow the Link Below.

Volunteer

ICIRR Intake Form

Basic Info of Primary Contact

Languages

Barriers

Case Management

Family Members

Family Members 2

Family Members 3

NAI ONLY

JOIN THE MOVEMENT!

Sign Up for Communication with QCAIR

Contact Us

ADDRESS

4709 44th St Suite 4, Rock Island, IL 61201

PHONE

(563) 594-0854.

EMAIL

qcair@qcair.org

Staff Resources

Media Kit

Media
Kit