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

AUTHORIZATION FOR RELEASE OF INFORMATION

For Ongoing Collaborative Service Partners
I, Name , authorize United Advocacy Group staff to exchange information pertinent to the coordinated provision of service to me and/or my family in participating in one of the following programs:
Family Strengthening Network

Compass Program

RE-Vision Project

Igniting Hope Initiative

Families to College

Stronger Families

Euphoria Life

Unidos Para La Familia

Family Advocate Supervised Visitation

Family Advocate Home Supervision Program
I understand that my records are protected under the federal and state confidentiality regulations and cannot be disclosed without my written consent, unless otherwise provided for in the regulations.

I understand that I may revoke this consent at any time, except to the extent that action has been taken in reliance on it.

I also understand that my information will be utilized for reporting purposes, but that all my personal information will be coded and no identifiable information will be included in the report.

I further acknowledge that the information to be released was fully explained to me and this consent is given on my own free will.

This authorization to release information will expire, if not revoked by me, in three years from date of execution.
Adult 1 Signature

Clear
Date

MonthDayYear
Date
Adult 2 Signature

Clear
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

Family 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.