Client Intake

Client Intake

NOTE: Have printed screening in front of you when you complete this form for ease of access.
Client ID (From Screening)*
Date of Intake

MonthDayYear
Date
Manner of Intake

PhoneIn Person
Service Coordinator*
Service Coordinator Email*
example@example.com
Intake Location
Client Legal Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Client Email (autosends copy of budget)
Be sure to print a copy of the budget for them if they do not have an email address.
Which of the following supporting documents did the client provide? (NOTE: We cannot proceed with intake until all applicable documentation is provided)

Drivers LicenseProof of IncomeCopies of BillsCopy of current lease agreement (for rent/deposit requests)Other
Verification of Contact Info & Address Provided from Screening? (If changes need to be made, make changes on printed copy and update screening after intake is completed.)

YesNo
Please scan or take a photo of supporting documents and upload here (You can also email to office@upliftmidmo.org after the intake.

Browse Files

Cancelof

Intake Disclaimers
Has the client, or anyone in the client's household received assistance from Uplift Mid-MO before?

YesNo
Do you give Uplift Mid-MO permission to verify the information you provide and share appropriate information with resources that may help you?

YesNo
Was a release of information signed?

YesNo
If no, click here to fill the release of information form.
Do you understand that Uplift is required to report any information that you give us about possible suicide, homicide, child abuse, or elder abuse to the appropriate authorities?

YesNo
Please Explain the Current Need in Detail:

Finances: Monthly Expenses Detail

Be sure to include MONTHLY ACTUAL amounts.
Housing Expenses
Rent/Mortgage
Renter's/Homeowner's Insurance
Electric
Gas
Water
Sewer/Trash
Maintenance/Lawn Care
Ex. Furnace Filters, Gas for Lawn Mower, Light Bulbs, etc.
Other Housing-Related Expenses
Anything else directly related to your home (non-subscription-based items).
TOTAL HOUSING EXPENSES
Housing Expense Notes

Monthly Debts & Other Payments

(Do not include Mortgage and Auto Loans here)
Credit Card 1
Credit Card 2
(IF additional lines are needed, include it in the other debt below)
Loan 1
Loan 2
Student Loan
Payday Loan
Title Loan
Alimony/Spousal Support
Child Support
Rent-to-Own
Other Debt Payment
TOTAL DEBT & OTHER PAYMENTS
Debt & Other Payment Notes

Barriers & Challenges
Have you experienced any life-changing events recently? (ex. death, divorce, disaster)

YesNo
Have you experienced any barriers or challenges that prevent you from being where you want to be in life?

YesNo
Do you have any current charges pending against you?

YesNo
Are you currently on probation or parole?

YesNo
Other notes about barriers & challenges:

Intake Disclaimers