Connection Request Form

Applicant Details:

1. Full Name

First NameLast Name

2. Gender

3. DOB

Date

4. Age

5. Last 4 of SSN

6. Are you currently experiencing homelessness or unstable housing? (This includes staying in shelters, living in a vehicle, temporarily staying with others, or not having a permanent place to live.)

7. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

8. Phone Number

Format: (000) 000-0000.

9. E-mail

example@example.com

10. Parent/Guardian or Emergency Contact Name (if applicable)

11. Parent/Guardian or Emergency Contact Number (if applicable)

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

12. Do you currently have Medicaid coverage?

13. Insurance Company

14. Member ID

15. Do you currently have an active life insurance policy?

16. Are you a U.S. military veteran?

17. Are you currently unemployed or seeking employment?

18. Have you ever been incarcerated or involved with the criminal justice system?

19. Are you currently on probation/parole?

20. Have you ever participated in therapy or received any mental health services, either currently or in the past?

21. If yes, please specify the type of service and approximate dates.

22. Do you currently have any mental health diagnoses or have you been diagnosed with any mental health conditions in the past? If yes, please specify:

23. Have you ever been hospitalized for a mental health related issue?

24. If yes, please provide any relevant details (e.g., date, reason, length of stay) if you feel comfortable sharing.

25. Please list any medications you are currently prescribed, or have been prescribed in the past, related to your mental or physical health. Please include dosage and frequency. (If applicable).

26. Do you currently use, or have a history of using, drugs or alcohol in a way that has caused problems in your life? (Your response will remain confidential.)

27. If yes, please briefly describe the substance(s) involved and whether you are currently receiving or have received treatment or support.

28. Please briefly describe the reason for your service request or the support you are seeking. This may include any challenges you are experiencing or goals you hope to achieve through the service.

29. Are you a parent or guardian?

30. Are you also seeking support or services for your child or children?

31. Are you currently experiencing or have you previously experienced any form of domestic or intimate partner violence? (This may include physical, emotional, mental, sexual, spiritual, or financial abuse. Your response is confidential.

32. Please provide any additional information, comments, or supporting details that may help us better understand your needs or assist in providing the appropriate support or services.

33. How did you hear about us?

By signing below, I authorize representatives of A Major Connection to coordinate services and access or share relevant information on my behalf with appropriate agencies, service providers, and individuals involved in supporting my needs. This may include personal, medical, educational, housing, employment-related, or any information necessary for effective service coordination and resource referrals. I understand that this authorization is voluntary and that I may revoke it at any time in writing. Unless revoked earlier, this release will remain in effect for one (1) year from the date of submission of this document. I acknowledge that once information is released, it may no longer be protected under certain privacy laws, but A Major Connection will make reasonable efforts to ensure the confidentiality of all shared information.

Signature

Date