Connection Request Intake Form

Connection Request Intake Form

IMPORTANT: Section 1 MUST be complete to submit this form. For the remainder of the application, if a question does not apply to you, enter "N/A" or "None." Please note that a separate application must be completed for EACH individual seeking services. Only ONE person may be included per application. Please call our intake coordinator or text "INTAKE" to 757-835-8817 for assistance.
Section 1
This application is being completed for a(n):
I am completing this application for:
Applicant Details

This information is about the individual seeking support.
1. Full Name

First NameLast Name
2. Gender
3. DOB

MonthDayYear
Date
4. Age
5. Last 4 of SSN
6. Please check all that you currently have reliable access to.
7. If you selected "None of the Above", would you like assistance obtaining communication or technology resources?
8. Phone Number (If you have limited access, please provide the best temporary phone number where we can reach you)
Format: (000) 000-0000.
9. E-mail (If you have limited access, please provide the best temporary email address where we can reach you)
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 have a preferred contact method?
13. Is there a best time to contact you?
14. Do you authorize us to leave messages via text/voicemail/email?
15. What city/county are you currently located in and where are you seeking services?
16. 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.)
17. Home Address (If you selected 'Yes' above, please provide an address which you can temporarily receive mail)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
18. Please describe the goals you hope to accomplish through our services and community partnerships.
Section 2
19. Do you currently have Medicaid coverage?
20. Insurance Company
21. Member ID
22. Highest Level of Education Completed
23. What type of support are you seeking from A Major Connection?
24. Are you currently experiencing an immediate safety crisis or emergency that requires urgent help today?
25. Are you currently without safe shelter tonight?
26. Do you currently have a child safety concern?
27. 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.
28. Are you currently or have you previously experienced any form of suicidal thoughts or self-harmed?
29. Are you currently or have you previously experienced any form of homicidal thoughts or aggressive behavior?
30. Are you currently having a medical emergency?
31. Which of the following are urgent concerns for you right now?
32. Which services are you interested in? (Check all that apply)
33. Do you currently have an active life insurance policy?
34. Are you a U.S. military veteran?
35. If you are a U.S. military veteran, what is your current discharge status?
36. Are you currently unemployed or seeking employment?
37. Do you currently have reliable transportation?
38. Are you interested in educational or vocational training opportunities?
39. Have you ever been incarcerated or involved with the criminal justice system?
40. Are you currently on probation/parole?
41. Have you ever participated in therapy or received any mental health services, either currently or in the past?
42. If yes, please specify the type of service and approximate dates.
43. 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:
44. Have you ever been hospitalized for a mental health related issue?
45. If yes, please provide any relevant details (e.g., date, reason, length of stay) if you feel comfortable sharing.
46. 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).
47. 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.)
48. If yes, please briefly describe the substance(s) involved and whether you are currently receiving or have received treatment or support.
49. Would you be interested in support groups, social activities, or recreational programming?
50. Would you like to be connected to faith-based resources or spiritual support?
51. Are you a parent or guardian?
52. Are you also seeking support or services for your child or children?
53. Are any of the following currently involved in your care/support?
54. Names/agencies if known
55. Do you have a preferred provider, agency, organization, or company that you would like us to consider when making referrals?
56. If yes, please list the provider(s) you would like us to consider? Please note: While we will make every effort to consider your preferences, referrals are based on provider availability, service needs, eligibility requirements, location, insurance acceptance, and other factors.
57. 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.
58. How did you hear about us?
By signing below and/or submitting this form, 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
Print Name

First NameLast Name
Date

MonthDayYear
Date
For Preparer's ONLY (If applicable)

If you are completing this form for someone else, please complete the following.
Preparer's Full Name

First NameLast Name
Relationship to Applicant
Professional Title/Role (If applicable)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Ext (If applicable)
Email Address
example@example.com
Organization/Agency Name (If applicable)
Organization Address (If Applicable)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Should be Empty:

Connection Request Intake Form

Section 1

Applicant Details

Section 2

For Preparer's ONLY (If applicable)