***Patient Intake Form***

Patient/Client Initial Intake Form

All information is confidential. Data is used to determine needs of the

community and helps access grants to fund the Transgender Health and Wellness Center.

By filling this out completely, not only are you helping yourself the data helps your siblings that are in need.
Email -
Email
example@example.com
Legal Name:

First NameMiddle NameLast Name
Chosen Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Age
City and Zipcode

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the primary reason you want to connect with the Transgender Health and Wellness Center?
Please check the services you are seeking at the Transgender Health and Wellness Center
What is the highest degree or level of school you have completed? What is the highest degree or level of school you have completed?
What is your annual income?
What is your current housing status?
Are you currently living with disabilities?
If you answered yes, do any of your disabilities prevent or severely limit your access to gainful employment?
Are you a veteran or currently serving in any branch of the US Military?
Have you ever been convicted of a felony?
Have you ever been on probation or parole?
Have you ever been in the Foster Care system?
Are you living in the US undocumented? (remember, answers are confidential)
Are you currently in the process of seeking asylum in the United States?
Sexual Orientation

Another Sexuality:
What is your gender/identity?

Another Identity
Do you identify as transgender?
Race/Ethnicity
Do you have what you need to get to work or important appointments? (a ride, money for gas - rideshare, taxi or transit?)
Do you usually have enough money to get the food you need?
Do you have access to a primary care provider?
When was the last time you were able to see your primary care provider?

MonthDayYear
Date
How do you pay for your healthcare?

Other
If applicable, what is your Medi-Cal managed plan? (Example: IEHP, Molina, Blue Promise etc)
Do you have access to a mental health care provider?
When was the last time you were able to see your mental health care provider?

MonthDayYear
Date
If you’ve never sought mental healthcare services. What prevented you from doing so?

Over the last two weeks, how often have you been bothered by the following problems? (not at all, Several Days, More than half the days, Nearly every day)

Rows	Not at all	Several Days	Several Days	More than half the days	Nearly every day
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Feeling down, depressed, or hopeless
Little interest or pleasure in doing things

Content Warning for next questions: “the following questions deal with topics that may be uncomfortable and deal with topics such as sexual health, your experience with violence or harrasment, and substance use”
Have you been dianosed with an STI/STD in the past 12 months? Select any/all that apply

Other
Are you familiar with PrEP?
Have you ever had to exchange sex for drugs, money, housing, and/or other resources?
Have you ever been sexually assaulted or been the victim of sexual assault?
Have you been the victim of sexual assault or domestic violence in the past 12 months?
Have you ever experienced harrassment while using public transprotation, such as a bus, Uber, or Lyft?
Have you used tobacco in the past 12 months?
In the past 12 months, have you used marijuana?
In the past 12 months, have you used drugs other than those required for medical reasons?
Date

MonthDayYear
Date
Have you ever thought of or attempted to die by suicide (past or present)?
What is your Hepatitis C status?
What is your HIV status?
Religion
Ethnicity
If you answered yes, do any of your disabilities prevent or severely limit your access to gainful employment?
Have you ever smoked cigarettes?
Identity:
Comments/Suggestions/Inquiries
Are there any accommodations you may need support with? (e.g.: disability, language, etc) Please list here and we will do our best to accommodate?
Wellness Center.
Would you like to be sent a full description of the services we provide and notified of future events?
Should be Empty:

Content Warning for next questions: “the following questions deal with topics that may be uncomfortable and deal with topics such as sexual health, your experience with violence or harrasment, and substance use”