Client Intake Form

Client Intake Form

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Client's Name*

First NameLast Name
Client's Gender*

MaleFemale
Client's Race*

CaucauisanAfrican AmericanHispanicAsianAmerican Indian/Native AmericanIslander
Date of Birth*

MonthDayYear
Date
Client's Phone Number*
Do we have permission to send text messages to the phone number provided?*

YesNo
Client's Email*
example@example.com
Current Living Situation*

Living in a shelterLiving in a carLiving in a hotelLiving with friend or relativeLiving on the streetHospital or facilityIncarceratedGroup home or shared housingOther
Housing Preference*

Shared spacePrivate room
How will the client pay for housing?*

SSI/SSDI (self-pay)RetirementVoucherOrganization PayOther
What is the client's monthly income? If none, please type "None."*
Move-In Date

MonthDayYear
Date
Does the client have a mental illness? If none, please type "none." If "yes" please describe.*
Does the client have any other disabilities? If so, please describe.*
Does the client require handicap accessibility?*
Representative's Name

First NameLast Name
Representative's Organization (i.e., Atlanta Mission, Restoration House, etc.)
Is the client an ex-offender?*

YesNo
Is the client a sex-offender?*

YesNo
Is the client currently on probation or parole?*

YesNo
Does the client need help with alcohol or substance abuse recovery?*

YesNo
Does the client need case management services?*

Health InsuranceFood stampsSSI/SSDIJob placementTransportationDay ProgramLife Skills GroupGroup TherapyIndividual TherapyCellphone/TabletClothing Donations
How did you hear about Olive Branch Independent Living LLC?*

Social MediaFlyer/BrochureSearch EngineReferralWord of mouth
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