Form

Form
General Intake Form
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
D.OB
Emergency Contact (Name)
Emergency Contact (Phone Number, and Relationship)

Confidentiality Agreement
Once you begin your work with a Key To The Streets Foundation, everything will be held confidential. Your communication will be protected by the state of Wisconsin. Information will be only released with your authorization. This is your right to privacy.

Limits of Confidentiality
- When an individual indicates that he/she is at risk of harming oneself or someone else.
- When law enforcement notify the agency or police when incideness or suspected criminmal activity.
- When ordered by a judge to release information or respond to paticular questions.
- When seeking assistance for addictions or mental health issues is protected under the federal law.
If you agree to the terms and condition:

Sign Below
Signature

Clear

COVID-19 Liability Waiver
Date

MonthDayYear
Date
Name

First NameLast Name
I acknowledge the contagious nature of the Covid-19 and that CDC any many other public health authorities still recommend practicing social distancing.

I further acknowledge that A Key To The Street Foundation Inc. has put in place a preventive measure to reduce the spread of the Covid-19.

I further acknowledge A Key To The Street Foundation Inc. can not guarentee that I will not become infected with Covid-19. I understand the risk of being exposed/infected. This may result from actions, omissions, negligence of myself and others, including, but not limited to the public.

I voluntarily seek services provided by A Key To The Street Foundation Inc. and acknowledge that I am increasing my risk of exposure to Covid- 19. I acknowledge that I must comply with all sets of procedures to reduce the spread while attending appoinments.
Signature

Clear

Getting to know You
Have you been incarcerated between 1-5 years periodically?

YesNoUnsure
Please explain your criminal background/history:
List what you need/want for the program:
What are your short and long term goals
Should be Empty: