OHL Client Intake Form

Open Heart Leaders Client Intake Form
Client Information

Please complete a separate intake form for each individual receiving services from Open Heart Leaders. All information provided is confidential and will not be sold or shared with any third-party agencies. For applicants under the age of 12, a parent or guardian must complete the entire form on their behalf. If your child is the client receiving services, please fill out the child’s information and submit a separate form for yourself as the parent or guardian.
Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Please enter a valid phone number. If filling for a minor please add parent or guardian phone number.Format: (000) 000-0000.
Additional Number
Please enter a valid phone number.Format: (000) 000-0000.
Email*
If filling out for minor please add parent or guardian email.
Additional Email
Clients Date of Birth*

MonthDayYear
Date
Gender*

FemaleMalePrefer Not To SayOther
Client Ethnicity*
Client Education Level*
Client Primary Language*
Program or Services Needed*

Counseling ProgramResource & Referrals (higher education, food, clothing, jobs etc...)Community Resource Education Support Team (C.R.E.S.T.) (Select if needing assistance with IEP and 504 plans) Open Heart Leaders is a certified NonPublic Agency (NPA) provider for the state of California.Heart Leaders Academy Program (High School Program for participants ages 15 - 29+ needing to acquire an Accredited High School Diploma)JDI Program (Select ONLY if you are referred through NCRC)
Insurance*

Medi-care (You will be notified once a provider becomes available.)AetnaN/A - If uninsured or not listed.
Insurance Card Front Side*
Insurance Card Back Side*
Photo I.D. *
Subscriber's Full Legal Name*

First NameLast Name
Is the Subscriber's date of birth same as above?*

YesNo
Subscriber's Date of Birth*

MonthDayYear
Date
Is the Subscriber's address the same as above?*

YesNo
Subscriber's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Insured *
Notes: Relationship to Insured
Referral Program (Who referred you to Open Heart Leaders?)*

JDI ProgramCRD (Community Resource Directory)Probation/ParoleCare SolaceSchool ReferralCommunity PartnerN/AOther Not Listed (Type Here)
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Email
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Applicant*
The remainder of the client intake form is a questionnaire that allows our agency to collect data and provide appropriate services and care. Please answer the following questions honestly to the best of your knowledge.
Household Size (How many people are in your home including you)*
What is your Household Income (if answering for a minor please select according to the parent or guardian)*

Less than $10,000$10,000 to $29,999$30,000 to $49,999$50,000 to $79,000More than $80,000Choose Not To Answer
Are you currently seeking employment? (Please answer NO if minor is below age limit to work or not actively seeking to work)

YesNo
Are you or a member of your household participating in any of the following services or programs? (please check all that apply).*

CALFreshWelfareMedi-CalMedicare (Individuals 65+)Section 8Public or Subsidized Housing AssistanceN/A
What is your primary mode of transportation to get to Open Heart Leaders? (If answering for a minor please select the minors mode of transportation)*

CarPublic Transportation (Bus, Trolley, Train, etc.)BicycleWalkingOther
How did you hear about Open Heart Leaders?*

Family or FriendOther OrganizationFacebookTwitterInstagramLinkedInOther
Contact Record Type Id
Should be Empty:

Open Heart Leaders Client Intake Form

Client Information

Emergency Contact Information