Client Intake Form
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Month
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Day
Year
Today's date
Name
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First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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Month
-
Day
Year
Date
Are you currently experiencing homelessness?
Yes
No
Prefer not to answer
County of residence
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Mendocino
Sonoma
Other
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you receiving any of the following benefits? Please select all that apply
CalFRESH
WIC
CalWorks
I do not receive any benefits
Other
Healthcare
Medi-Cal
Covered CA
Partnership
Other
I do not have insurance
What is the name of your insurance provider?
Do you identify as part of the LGBTQIA+ community?
Yes
No
Prefer not to answer
Preferred pronouns
Please Select
She/her
He/him
They/them
My preferred gender identity is:
Please Select
Female
Male
Non-binary
Prefer not to say
Other
Ethnicity (select all that apply)
Latino/a
Caucasian/White
Black/African-American
Native/First Nations
Asian/Pacific Islander
Other
Mixed
Unknown
Prefer not to say
Are you a veteran?
Yes
No
Single Parent
Yes
No
Do you have a disability?
Physical
Hearing
Visual not to answer
Learning
Other
Prefer not to answer
I do not have a disability
What is the primary language spoken at home?
Spanish
English
Chinese
Creole
Other
Are you filling this form out on behalf of a child or children in your household?
Yes
No
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How many children are in your household?
Please Select
1
2
3
4
5
More than 6
Name of Child 1
Child 1 First Name
Child 1 Last Name
Child 1 Date of Birth
-
Month
-
Day
Year
Child 1 Date of birth
Child 1 Gender
Female
Male
Nonbinary
Child 1 Disabilities
Yes
No
Child 1 School
Please Select
Greenwood Day Care
Point Arena Pre-school
South Coast Day Care
Forager Day Care
MPA Headstart
Arena Elementary
Manchester Elementary
Kashia Elementary
Point Arena High School
Pacific Community Charter School
South Coast Continuation School
Homeschool
My child is not in school
Name of Child 2
Child 2 First Name
Child 2 Last Name
Child 2 Date of Birth
-
Month
-
Day
Year
Child 2 Date of birth
Child 2 Gender
Female
Male
Nonbinary
Child 2 Disabilities
Yes
No
Child 2 School
Please Select
Greenwood Day Care
Point Arena Pre-school
South Coast Day Care
Forager Day Care
MPA Head Start
Arena Union Elementary School
Manchester Elementary
Kashia Elemetary
Point Arena High School
Pacific Community Charter School
South Coast Continuation School
Homeschool
My child is not in school
Child 2 School
Name of Child 3
Child 3 First Name
Child 3 Last Name
Child 3 Date of Birth
-
Month
-
Day
Year
Child 3 Date of birth
Child 3 Gender
Female
Male
Nonbinary
Child 3 Disabilities
Yes
No
Child 3 School
Please Select
Greenwood Day Care
Point Arena Pre-school
South Coast Day Care
Forager Day Care
MPA Headstart
Arena Union Elementary
Manchester Elementary
Kashia Elementary
Point Arena High School
Pacific Community Charter School
South Coast Continuation School
Homeschool
My child is not in school
Child 3 School
Name of Child 4
Child 4 First Name
Child 4 Last Name
Child 4 Date of Birth
-
Month
-
Day
Year
Child 4 Date of birth
Child 4 Gender
Female
Male
Nonbinary
Child 4 Disabilities
Yes
No
Child 4 School
Please Select
Greenwood Day Care
Point Arena Pre-school
South Coast Day Care
Forager Day Care
MPA Headstart
Arena Union Elementary
Manchester Elementary
Point Arena High School
Kashia Elementary
Pacific Community Charter School
South Coast Continuation School
Homeschool
My child is not in school
Child 4 School
Name of Child 5
Child 5 First Name
Child 5 Last Name
Child 5 Date of Birth
-
Month
-
Day
Year
Child 5 Date of birth
Child 5 Gender
Female
Male
Nonbinary
Child 5 Disabilities
Yes
No
Child 5 School
Please Select
Greenwood Day Care
Point Arena Pre-school
South Coast Day Care
Forager Day Care
MPA Headstart
Arena Union Elementary
Manchester Elementary
Kashia Elementary
Point Arena High School
Pacific Community Charter School
South Coast Continuation School
Homeschool
My child is not in school
Child 5 School
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Adults in home
How many adults live in your household?
1 (only me)
2
3
4
5
6
7
8
9
10
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Adult 2 Name
Adult 2 First Name
Adult 2 Last Name
Adult 2 Date of Birth
-
Month
-
Day
Year
Adult 2 Date of Birth
Adult 2 Ethnicity
Please Select
Latino/a
Caucasian/White
Black/African-American
Native/First Nations
Asian/Pacific Islander
Other
Adult 2 Gender
Please Select
Female
Male
Non-binary
Adult 2 Disabilities
Yes
No
Adult 3 Name
Adult 3 First Name
Adult 2 Last Name
Adult 3 Date of Birth
-
Month
-
Day
Year
Adult 3 Date of Birth
Adult 3 Ethnicity
Please Select
Latino/a
Caucasian/White
Black/African-American
Native/First Nations
Asian/Pacific Islander
Other
Adult 3 Gender
Please Select
Female
Male
Non-binary
Adult 3 Disabilities
Yes
No
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How did you hear about Action Network?
Word of mouth/from friends or family
My child's school
Community Event
Radio Advertisement
Other
What is the primary reason for your visit today?
Parental support
Youth services
Diaper services
Counseling / mental health
Food support
Support with applications and paperwork
Referral to other agencies
Other
If you selected "other" please explain.
May we add you to our newsletter?
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By checking this box, I agree to allow Action Network to use my demographic information for statistical and reporting purposes only.
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