Family Intake Form

This LifeWise StL Family Intake Form is meant to be completed by an adult on behalf of their entire family.

FAMILY INFORMATION

How many family members live in your house (including yourself)?

Address

Street Address

CityState

Zip Code

Annual Household Income

Please estimate the combined incomes of all adult family members in your household for the last 12 months.

PERSONAL INFORMATION

Once you've submitted this form with your own information, you'll be prompted to complete it again for each additional family member who lives in your house. For example, if 4 people live in your house, you should complete this form 4 times. Some of the fields will prefill to save you time on each subsequent form.

Case Number

As displayed on ETO Profile

DO NOT USE - OG Name Field - Replaced

First NameMiddle NameLast Name

First Name

Middle Name

Last Name

Suffix

If applicable

Date of Birth

Date

Gender

Age

Self Defined/Other Gender

Today's Date

Date

Is this person a parent/guardian for youth participants in the household?

Marital Status

Program Participation

Is this person enrolling in programming?

Which program is this person enrolling in?

**This is NOT an application for programming. Selecting a program from this list does not guarantee you a spot in that program. If you'd like information on how to apply for one of the programs above, please reach out to the person who shared this form with you**

Contact Information

Preferred Name

If different from legal name

Preferred Pronouns

e.g. She/Her, He/Him, They/Them

Primary Phone Number

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

Can we text the primary phone?

Secondary Phone Number

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

Can we text the secondary phone?

By submitting this form and signing up for texts, you consent to receive text messages (e.g. program information and other correspondence) from LifeWise StL at the number(s) provided, including messages sent by autodialer. Consent is not a condition of participation. Msg & data rates may apply. Msg frequency varies. At any time, if you wish to no longer receive texts from LifeWise StL, reply to any message with STOP. Reply HELP for help. Privacy Policy & Terms.

Email

example@example.com

Preferred Language (Check all that apply):

Other Language

If program services are being offered in multiple languages, a staff person will connect with your family to determine in which language the participant(s) would prefer to receive services.

Emergency Information

Please list all health conditions, allergies, and/or dietary restrictions you'd like us to be aware of:

If not applicable, leave blank

Emergency Contact (#1)

First and Last Name

Relationship (#1)

Phone Number (#1)

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

Alternate Phone Number (#1)

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

Emergency Contact (#2)

First and Last Name

Relationship (#2)

Phone Number (#2)

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

Alternate Phone Number (#2)

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

Demographic Information

Please be assured that your answers to the questions below are completely voluntary and will not affect your access to services in any way. Your responses are used solely for statistical purposes and to help improve our programs.

Please select below all the races/ethnicities you identify with

Country of Birth

Other Country of Birth

After submitting this form, please remember to click the available link & complete the form again for each additional family member who lives in your house.

Please list an emergency contact. This information ensures we can reach someone you trust to assist you promptly in an emergency.