UAG Intake Form

UAG Intake Form
Family Advocate's Name
Person who sent you the forms to fill out
Adult 1: Full Name
Date of Birth(DOB)

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

Zip
Home Phone
Cell Phone
Email
example@example.com
Marital Status
Marital Status
Gender
Race/Ethnicity
Race/Ethnicity
Adult 2: Full Name
Date of Birth(DOB)

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

Zip
Home Phone
Cell Phone
Email
example@example.com
Relationship to Adult 1
Gender
Race/Ethnicity
Race/Ethnicity
Marital Status
Marital Status

Children's Names

	Name	Date of Birth	School	Grade	IEP/504/Concerns
1.
2.
3.
4.
5.
6.

Preferred Communication:

PhoneTextEmail
Do you consent to receive texts?

YesNo
Do you consent to receive emails?

YesNo
Is it safe to contact you via: (check all that apply)

Cell phoneLeave a voicemailText messageEmailOther
Best time to reach you:

MorningAfternoonEvening
Adult 1: Employment Status

Full-timePart-timeUnemployedStudent
Adult 2: Employment Status

Full-timePart-timeUnemployedStudent
Adult 1: Education Level

High School/GEDSome CollegeBachelor's DegreeMaster's DegreeCurrent Student
Adult 2: Education Level

High School/GEDSome CollegeBachelor's DegreeMaster's DegreeCurrent Student
Does everyone in the home have health insurance?

YesNo
Is anyone in the home a veteran?

YesNo
Number living in household
Household Monthly income
(This helps us screen for resources and services)
Household Annual Income

$0 - $10,000$10,001 - $20,000$20,001 - $30,000$30,001 - $40,000$40,001 - $50,000$50,001 - $60,000$60,001 - $70,000$70,001 - $80,000$80,001+
Which goal area(s) are you interested in addressing? (check all that apply)

FinancesEmploymentMental HealthFamily RelationshipsParentingLife SkillsLegal IssuesPhysical HealthImmigration IssuesSubstance AbuseHousingEducationCollege ReadinessDomestic ViolenceBudgetingChild DevelopmentUtility AssistanceDebt ReductionCareerElder CareOther
Have you or a member of your family ever been a victim of a crime(ex. assault, robbery, domestic violence, etc.)?
How did you hear about us / Referred by?
Emergency Contact
Emergency Contact Phone Number
Other agencies you receive services from?

DCPPCMOCFSCourt ConnectedTherapyCounselingSA TreatmentCASA

Family Participation Agreement
I, Name, and my family, understand that participation in the United Advocacy Group programs are voluntary. I understand that we may exit the program at any time. I understand that all of the information shared with UAG staff is confidential unless I give permission to release information to a specific source. No personal information will be shared except in certain life and death emergencies or mandated by court order. I also understand that if a person seriously believes that I intend to harm myself or others, or suspects child or elderly abuse/neglect, he/she is legally and ethically bound to report this information to the appropriate authorities.

I agree to participate with the UAG Advocate to define my family’s goals and needs, and to set a clear path towards reaching our goals. My family’s responsibility is to actively take steps forward using the help and assistance of the UAG Advocate with the goal of self-sufficiency. The UAG Advocate will provide accountability for the family. I understand this program does not provide financial resources.

I have read, understand, and accept the above statements. I hereby give my consent to receive support as deemed beneficial to me and my family, and will be an active participant in the process.
Adult 1 Signature

Clear
Date

MonthDayYear
Date
Adult 2 Signature

Clear
Date

MonthDayYear
Date
UAG Advocate Commitment Pledge
As a UAG Advocate, I will work alongside this individual/family, helping them define goals and steps to achieve those goals. I will serve with professionalism and will respect the confidentiality of their information. I will connect them to appropriate community resource, and provide consistent follow-up and encouragement in guiding them to achieve their goals. I will strive to equip them with tools for future self-sufficiency. I commit to working as hard for this individual/family as they are willing to work for themselves.

Client Notice of Rights/Confidentiality Form
As a client of United Advocacy Group, you have the following rights regarding the confidentiality of your personal information and communications with UAG staff and volunteers:
1. The information that you provide to United Advocacy Group will be kept confidential to the greatest extent of the law.
2. You may choose what information you want to provide to UAG. You will not be denied access to services if you choose not to provide certain identifying information.
3. The information that you provide to United Advocacy Group, including your name, address, phone number and other personal information will not be shared with other individuals or agencies without your permission.
4. United Advocacy Group staff may be required by law to report certain situations even if you do not give them permission to share or report the situations, such as suspected child abuse or neglect. We are also required to contact law enforcement when there is potential suicidal behavior or threat of harm to others that is likely to result in a clear, imminent risk of serious physical injury or death to you or another person.
5. Some general information about types of services provided and overall demographics (e.g. age, income ranges, # of children, ethnicities, etc.) of people that use United Advocacy Group services must be shared with grantors that fund UAG programs. However, information that specifically could identify you as someone who received services will never be shared unless specifically authorized in writing by you.
6. After your intake with United Advocacy Group, you may choose to be referred to other agencies for additional help and support. You can decide how much or how little of your personal information you would like UAG to share with a partner agency on your behalf. If you choose to have UAG share your personal information with a partner agency, you will be told exactly how and what information will be shared. If you later decide that you do not want the information you have provided to be shared with any other UAG partner, you may rescind your authorization.
7. If you have any questions or concerns about this notice or your rights, or if you have a concern that your confidential information was not treated appropriately, please contact the Director of Family Advocacy – rachael@unitedadvocacygroup.org
8. By signing below, you are consenting to participate in services. You have read the information given or someone has read it to you and have reviewed and agree to the UAG Privacy Policy. You have had the opportunity to ask questions, which have been answered satisfactorily by staff.
Adult 1 Signature

Clear
Adult 1 Name
Date

MonthDayYear
Date
Adult 2 Signature

Clear
Adult 2 Name
Date

MonthDayYear
Date

I / We certify that to the best of my/our knowledge and belief all of the information on this form is true and accurate.
Adult 1 Signature

Clear
Date

MonthDayYear
Date
Adult 2 Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

UAG Intake Form

Family Participation Agreement

UAG Advocate Commitment Pledge

I / We certify that to the best of my/our knowledge and belief all of the information on this form is true and accurate.