Unsuccessful Intake Form
Please Complete This Form After a Member Has an Unsuccessful Intake. Reasons to Use This Form Include: No-Show, Failed UA, etc.
Name of the Member
*
Date and Time of Scheduled Intake
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Name of Manager Filling out This Form
*
First Name
Last Name
House Name
*
Bryant Gardens
Jay
Penrose
Sully
Tufts
Twin Lakes
Winona
Zuni
What is the Reason for the Unsuccessful Intake?
*
No-Show
Failed UA
Other
Additional Notes For Management Regarding Unsuccessful Intake
Submit
Should be Empty: