General Intake Form

Legal Name

First NameLast Name

Preferred Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Ok to leave message?

Email

example@example.com

Emergency Contact Name:

First NameLast Name

Emergency Contact Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Pronouns:

Select all that apply:

How did you hear about the Women's Center?

Do you consider yourself head of household?

Ethnic Background:

Age: Date of Birth: blank

Number of dependents: Type a label
Step-children? Yes No If yes, how many?

Level of Education:

Ex-offender

Other

If yes, Felony?

If yes, Misdemeanor?

Do you have health insurance?

Barriers to success (Select all that apply):

Do you feel safe in your intimate relationship?

Do you want information on safety planning today?

Are you a person with a disability?

Will this affect education or employment?

Are you employed?

Hourly rate: . Annual/Hourly Rate: .

Total Monthly Income: blanks

Do you have a computer to use at home?

Are you registered to vote?

Have you served in the military?

Will you have difficulty getting to the Women's Center for activities?

What services are you interested in receiving?

Client Bill of Rights and Responsibilities

You have legal rights when you receive services from the Women's Center. The Michigan Mental Health Code and other Laws safeguard those rights. Our staff, volunteers and interns are responsible for protecting your rights when they provide services to you. You are encouraged to ask questions about your treatment and about your rights if you have them and you should make suggestions that you feel are in our best interest. If you believe your rights have been violated, please address the issue with your counselor or request an interview with a Women's Center staff member.

All personnel, volunteers, staff, and interns uphold the following Client Bill of Rights:

Clients have the right to:

- be treated with dignity and respect

- have a treatment plan for their services and a right to participate in the development of that plan

-have access to their own case records

-privacy and confidentiality.

Information discussed and files are strictly confidential. No information about you or from your file will be released without your written permission. Confidentiality is not absolute and there are circumstances in which information can and must be released. Legally mandated exceptions to this policy include instances in which life is in danger, or if you disclose information about current elder abuse, child abuse, or molestation.

- cultural, ethnic, and gender sensitivity, religious freedom and the right not to be discrimination against

- informed consent and will be informed of the purpose, risks, and benefits of service, the limits of services and choices regarding services

- complain and will have the means to do so

- be safe and free from exploitation

- to refuse services

- integrity

- have their own welfare put first

- be told about any time delays, interruptions, changes or termination of services

- to be told about client rules, expectations and responsibilities

- free access and considerations around disabilities

- a clean and safe environment.

As a client, you also have the responsibility to:

-be respectful towards staff, volunteers, and other clients.

-respect the confidentiality of other clients.

-attend scheduled appointments or provide advance notice of cancellations.

Termination of Services:

We reserve the right to terminate services if:

-you engage in behavior that is harmful to yourself, others, or the Women's Center community.

-you repeatedly fail to adhere to the terms of this agreement.

Agreement:

I have read and understand the terms of this client agreement form. I agree to abide by the policies and procedures outlined herein.

Client Signature

Date: blanks