Capital District LATINOS - Intake Package

Universal Intake Form

Your Information Helps Us Serve You Better
Client ID:
Agency Signature
Date

MonthDayYear
Date
Welcome to the Universal Intake form for Capital District LATINOS!

Your participation in completing all the fields in this form is crucial to help us better understand your needs and provide the best possible support. Whether you're seeking health services, educational programs, or community assistance, each detail you share will enable us to tailor our services to meet your unique needs. Please take a moment to carefully fill out every section. Your information is safe with us, and your input will directly contribute to the effectiveness of our programs.

Thank you for being a part of our community!
Head of Household Information

Essential Details for Primary Contact
Head of Household

Head of Household
Name*

First NameLast Name
Birthdate*

MonthDayYear
DOB
Do you authorize CDL to add your picture to your digital profile?*

YesNo
Picture of the Head of Household
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*

Albany CountyRensselaer CountySaratoga CountySchenectady CountyOther
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Demographics

Help Us Understand and Serve Our Community Better
Gender*

FemaleMaleNon-BinaryPrefer Not to AnswerNot Disclosed
Race*

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite or CaucasianSome other RaceOther / Multiple RacesPrefer Not to AnswerNot Response
Primary Home Language*

EnglishSpanishArabicChineseAmerican Sign Language (ASL)FrenchRussianVietnameseHaitianDutchNot DisclosedOther
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoPrefer not to AnswerUnknown
Cultural Identity*

Puerto Rican, Boricua, or TainoDominicanMexicanEcuadorianPeruvianSalvadoranGuatemalanCosta RicanNicaraguanArgentinianChileanCubanHonduranPanamanianBolivianColombianParaguayanUruguayanVenezuelanBrazilianDo Not Apply
Government Benefits*

SNAPTANFSection 8/ VoucherSSI or SSAMedicaidChildcare SubsidyNone
Do you receive Medicaid?*

YesNo
Medicaid Insurance Photo
TEFAP - Category

Option 1Option 2
Were you born in the United States*

YesNo
Country of Origin*
What is your immigration status?

CitizenConditional ResidentPermanent ResidentNon-Immigrant StatusUndocumented StatusUnknown
Household Members

Information About Everyone in Your Home
Household Size (Number of individuals living in the Household)*
Number of people in your household.
What is your Annual Income

$0 to $33,885$33,885 to $45,990$45,990 to $58,095$58,095 to $70,200$70,200 to $82,305$82,305 to $94,410$94,410 to $106.515$106.515 to $118,620
Additional Family Member # 1
Name (Family Member 1)

First NameLast Name
Date of Birth (Family Member 1)

MonthDayYear
Date
Gender (Family Member 1)

MaleFemaleNon-BinaryOther
Relationship with Head of Household (Family Member 1)

FatherMotherSonDaughterHusbandWifePartnerGrandmotherGrandfatherGrandparentGrandsonGranddaughterSpouseSibling
Gender (Text) - Member 1
Relationship (Text) - Member 1
Additional Family Member # 2
Name (Family Member 2)

First NameLast Name
Date of Birth (Family Member 2)

MonthDayYear
Date
Gender (Family Member 2)

MaleFemaleNon-BinaryOther
Relationship with Head of Household (Family Member 2)

FatherMotherSonDaughterHusbandWifePartnerGrandmotherGrandfatherGrandparentGrandsonGranddaughterSpouseSibling
Gender (Text) - Member 2
Relationship (Text) - Member 2
Additional Family Member # 3
Name (Family Member 3)

First NameLast Name
Date of Birth (Family Member 3)

MonthDayYear
Date
Gender (Family Member 3)

MaleFemaleNon-BinaryOther
Relationship with Head of Household (Family Member 3)

FatherMotherSonDaughterHusbandWifePartnerGrandmotherGrandfatherGrandparentGrandsonGranddaughterSpouseSibling
Gender (Text) - Member 3
Relationship (Text) - Member 3
Additional Family Member # 4
Name (Family Member 4)

First NameLast Name
Date of Birth (Family Member 4)

MonthDayYear
Date
Gender (Family Member 4)

MaleFemaleNon-BinaryOther
Relationship with Head of Household (Family Member 4)

FatherMotherSonDaughterHusbandWifePartnerGrandmotherGrandfatherGrandparentGrandsonGranddaughterSpouseSibling
Gender (Text) - Member 4
Relationship (Text) - Member 4
Additional Family Member # 5
Name (Family Member 5)

First NameLast Name
Date of Birth (Family Member 5)

MonthDayYear
Date
Gender (Family Member 5)

MaleFemaleNon-BinaryOther
Relationship with Head of Household (Family Member 5)

FatherMotherSonDaughterHusbandWifePartnerGrandmotherGrandfatherGrandparentGrandsonGranddaughterSpouseSibling
Gender (Text) - Member 5
Relationship (Text) - Member 5
Additional Family Member # 6
Name (Family Member 6)

First NameLast Name
Date of Birth (Family Member 6)

MonthDayYear
Date
Gender (Family Member 6)

MaleFemaleNon-BinaryOther
Relationship with Head of Household (Family Member 6)

FatherMotherSonDaughterHusbandWifePartnerGrandmotherGrandfatherGrandparentGrandsonGranddaughterSpouseSibling
Gender (Text) - Member 6
Relationship (Text) - Member 6
Additional Family Member # 7
Name (Family Member 7)

First NameLast Name
Date of Birth (Family Member 7)

MonthDayYear
Date
Gender (Family Member 7)

MaleFemaleNon-BinaryOther
Relationship with Head of Household (Family Member 7)

FatherMotherSonDaughterHusbandWifePartnerGrandmotherGrandfatherGrandparentGrandsonGranddaughterSpouseSibling
Gender (Text) - Member 7
Relationship (Text) - Member 7
Additional Family Member # 8
Name (Family Member 8)

First NameLast Name
Date of Birth (Family Member 8)

MonthDayYear
Date
Gender (Family Member 8)

MaleFemaleNon-BinaryOther
Relationship with Head of Household (Family Member 8)

FatherMotherSonDaughterHusbandWifePartnerGrandmotherGrandfatherGrandparentGrandsonGranddaughterSpouseSibling
Gender (Text) - Member 8
Relationship (Text) - Member 8
Dietary and Allergy Needs

Ensuring Your Health and Safety
Do you have any of the following Dietary Needs?

Low SugarLow SodiumGluten FreeKosherVegetarianHalalNo Dietary Needs
Any food allergy?

YesNo
What are your full allergy/allergies?
Informed Consent and Attestation of Eligibility
Do you have any questions?

YesNo
What are your questions?
I was given the opportunity to ask questions.

YesNo
I agree to share my information.

YesNo
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Universal Intake Form

Welcome to the Universal Intake form for Capital District LATINOS!

Thank you for being a part of our community!

Head of Household Information

Demographics

Household Members

Additional Family Member # 1

Additional Family Member # 2

Additional Family Member # 3

Additional Family Member # 4

Additional Family Member # 5

Additional Family Member # 6

Additional Family Member # 7

Additional Family Member # 8

Dietary and Allergy Needs

Informed Consent and Attestation of Eligibility