Case Management Services Client Information Form
Site Location and District
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Please Select
5429 Chestnut St, District 6
Intensive Resource Case Manager
Jala McDaniel
Saniyyah Byrd
Today's Date
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-
Month
-
Day
Year
Date
Email
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example@example.com
Phone Number
*
Please enter a valid phone number.
Full Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Date of Birth
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-
Month
-
Day
Year
Date
Age
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Race
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Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Specific Islander
White
Prefer not to say
Ethnicity
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Sex given at birth
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Is your gender the same as what you were given at birth?
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Yes
No
What is your gender identity?
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Male
Female
N/A
Other
What are your preferred pronouns?
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She/Her
He/Him
They/Them
Other
Is your primary language English?
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Yes
No
If not, what is your primary language?
What language do you want us to speak with you in?
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Have you graduated/completed high school?
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Yes
No
Currently in school
Have you attended college?
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Yes
No
Currently in school
Were you educated in Pennsylvania (PA)?
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Yes
No
Did you receive primary education in Philadelphia?
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Yes
No
Are you currently employed?
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Yes
No
If not, do you have any income?
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Yes
No
Do you feel financially secure?
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Yes
No
Do your expenses outweigh your income?
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Yes
No
Do you have access to affordable housing?
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Yes
No
What is your current living Situation?
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Family Home
Live Alone
Shelter
Homeless
Other
How many people are in your household?
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Do you need assistance with personal care or basic home essential items?
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Yes
No
Do you have health insurance?
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Yes
No
Do you have healthcare providers in your area that meets your needs?
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Yes
No
Have you ever been cared for or treated by a practitioner of color?
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Yes
No
Have you experienced or received quality care from your providers?
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Yes
No
Do you feel that your care provider is culturally aware and culturally competent?
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Yes
No
Have you ever felt discriminated against when seeking health care?
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Yes
No
Has any of your providers spoken to you in your native language?
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Yes
No
Do you feel comfortable with receiving services from a practitioner of color?
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Yes
No
Have you been referred to mental health resources?
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Yes
No
Are you currently stressed?
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Yes
No
Do you feel safe?
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Yes
No
If no, please explain why?
Do you know where the police station is in your neighborhood?
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Yes
No
Have you or a household member been a victim of police violence in the past 12 months?
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Yes
No
Have you been an aggressor of violence in the past 12 months?
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Yes
No
Have you been a victim of any type of violence in the past 12 months?
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Yes
No
Are you in walking distance of a local grocery store?
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Yes
No
Have you experienced hunger in the past 30 days?
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Yes
No
Do you have access to walkable playgrounds or parks?
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Yes
No
Do you need help with finding legal services?
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Yes
No
Do you feel a part of your local community?
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Yes
No
Do you have a support system?
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Yes
No
If yes, what does your support system look like?
Do you know how to access resources in your neighborhood?
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Yes
No
If yes, what resources do you have access to now in your neighborhood?
Have you been referred to resource sites?
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Yes
No
Do you need help with accessing resources?
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Yes
No
If yes, what are your specific needs?
If you have any additional information you would like to share with us, please leave it below.
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