Intake and Release of Information

Intake Form

For Valley Stream Benevolent Association
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Occupation and Employer
Marital Status
Family Composition- list household members
Why are you seeking assistance at this time?
Family Medical History
Any hospitalizations, serious illnesses, medical conditions, or health concerns for yourself or family members? (If yes, describe and give dates)

Do you or any of your immediate family have difficulty with any of the following:

	Yes/No	If yes, describe, include who and if receiving treatment.
Sleep
Appetite/Eating
Alcohol
Drugs
Suicidal Thoughts
Self-harm
Anxiety/Panic Attacks
Depression
Phobias
Anger Management
Body Image
Learning Difficulties

Are you interested in counseling for yourself or immediate family member? If yes, describe.
Benefits

Do you receive any of the following?

	Amount
SSI/SSD
Unemployment
SNAP/Food Stamps
Public Assistance/Temporary Assistance
Other
Total

Do you have health coverage:

	Yes	No
Health Insurance
Medicaid

Finances

Refer to the initial application you completed with VS Benevolent Association to assist in completing this section.

Income and Expenses Summary

	Amount
Annual Income (Salary, Wages, Tips)
Checking and Savings Balance
How many homes do you own?
Total Mortgage Balance
Total College Loan Balance
Monthly Mortgage Payment
Monthly Rent Payment
Total Monthly Income
Total Monthly Expenses
Monthly Net Income

Consent for Release of Information
Name

First Name Last Name
Date of Birth

Month Day Year
Date
I give permission for the Valley Stream Benevolent Association Trustees to communicate with Beverly Torres, LCSW to share recommendations and coordinate services. This consent will expire 180 days from today's date.
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Intake Form