LassenLinks Intake Form

Name*

First NameLast Name

Caregiver Email*

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Adult Race and Ethnicity (check all that apply)*

Primary Language*

EnglishSpanishTonganOther

How many people at these ages are in the household?

	Number in household
0 -2 years old
3-5 years old
6-12 years old
13-17 years old
Adults

Self-Referral Consent Language

By providing my information on this form, and through my signature below, I consent to share my contact information and any other information provided through this form for the following purposes:

To support linkages and/or referrals for services to other agencies, and
To support program evaluation, quality improvement activities, and reporting.
I understand that the information I provide may be used in publicly available reports in a de-identified or aggregated form, but that any personally identifiable information I submit through this platform will never be published or included in those reports.

Signature of Person*

Is there a child you are referring?*

YesNo

LassenLinks Intake Form

SERVICING AGENCY/FACILITY INFORMATION

ADULT/CAREGIVER/LEGAL GUARDIAN INFORMATION

Dependendent Information

Specific referral requests