***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*
Age*

17 or under18-2525-3031-4041-5051-6061-7071 or above
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*

Referral to medical carePeer/Emotional SupportMental Health ServicesSupport GroupsClothingFoodPet FoodHousing ReferralServices ReferralSuicide Education and PreventionHIV/HEP C Education and PreventionCrisis InterventionHair RemovalVolunteeringYouth AssistanceSubstance Intervention and RecoveryLegal Assistance ReferralName &/or Gender Marker ChangeFamily Support GroupEmployment AssistanceSafer SpaceTrainingHealth Care AdvocacyAssistance with HouselesnessSupport with my identity at the workplacePolicy Review/RecommendationsResume HelpMailing AddressSomething that is not listed
What is the highest degree or level of school you have completed? What is the highest degree or level of school you have completed?

less than high school diplomaHigh school diploma or GEDSome college but no degreeAssociates degree, Bachelors Degree, Masters Degree
What is your annual income?*

No income$9,999 or less$13,000 or less$25,000 or less$35,000 or less$35,001 or more
What is your current housing status?*

My housing situation feels safe and I have no risk of being evictedMy housing situation is unsafe and I am at risk of being evictedMy housing is unsafe and/or I am experiencing houselessnessAnother situation not listed
Are you currently living with disabilities?

YesNoNo Answer
If you answered yes, do any of your disabilities prevent or severely limit your access to gainful employment?

YesNoNot Applicable
Are you a veteran or currently serving in any branch of the US Military?

YesNoNo Answer
Have you ever been convicted of a felony?

YesNoNo Answer
Have you ever been on probation or parole?

YesNoNo Answer
Have you ever been in the Foster Care system?

YesNoNo Answer
Are you living in the US undocumented? (remember, answers are confidential)

YesNoNo Answer
Are you currently in the process of seeking asylum in the United States?

YesNoNo Answer
Sexual Orientation*

LesbianGayBisexualHeterosexualQueerAsexualPansexualAnother Sexuality:
What is your gender/identity?*

Man (either cis gender or trans gender)Woman (either cis gender or trans gender)genderqueergenderfluidNon BinaryAgenderintersexAnother Identity
Do you identify as transgender?

YesNo
Race/Ethnicity*

Black or African AmericanIndigenous / Native AmericanLatinX/o/a/ HispanicAsianNative Hawaiian/ Pacific IslanderWhiteAnother Identity (please specify)
Do you have what you need to get to work or important appointments? (a ride, money for gas - rideshare, taxi or transit?)

AlwaysSometimesRarelyNever
Do you usually have enough money to get the food you need?

AlwaysSometimesRarelyNever
Do you have access to a primary care provider?

YesNo
When was the last time you were able to see your primary care provider?

MonthDayYear
Date
How do you pay for your healthcare?

Private Insurance (self-paid ex.: Covered California)Health insurance through workMedicaid/Medi-CalMedicare (65+)I pay out-of-pocketFree ClinicsOther
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?

YesNo
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)

	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

chlamydiagonorrheasyphilisherpeshepatitisHIVno/noneno answerOther
Are you familiar with PrEP?

Very FamiliarSomewhat FamiliarNot Familiar
Have you ever had to exchange sex for drugs, money, housing, and/or other resources?

YesNoNo Answer
Have you ever been sexually assaulted or been the victim of sexual assault?

YesNoNo Answer
Have you been the victim of sexual assault or domestic violence in the past 12 months?

YesNoNo Answer
Have you ever experienced harrassment while using public transprotation, such as a bus, Uber, or Lyft?

YesNoNo Answer
Have you used tobacco in the past 12 months?*

NoYes
In the past 12 months, have you used marijuana?*

NoYes
In the past 12 months, have you used drugs other than those required for medical reasons?*

NoYes
Date*

MonthDayYear
Date
Have you ever thought of or attempted to die by suicide (past or present)?*

YesNo
What is your Hepatitis C status?*

NegativePositiveUndisclosed
What is your HIV status?*

NegativePositiveUndisclosed
Religion*

ChristianityIslamBuddhismHinduismIndigenous / Native religion or practicesNonreligious / AtheistAgnosticSpiritualNone of the AboveNot Specified
Ethnicity*

Hispanic, LatinX/o/a or Spanish OriginNot of Hispanic, LatinX/o/a or Spanish Origin
If you answered yes, do any of your disabilities prevent or severely limit your access to gainful employment?

yesnonot applicable
Have you ever smoked cigarettes?*

NoYes
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.*

I Agree
Would you like to be sent a full description of the services we provide and notified of future events?*

YesNo
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”