Intake For Potential Clients In Need*
MMHF *If form is not filled out in its entirety we cannot proceed with your intake.
**Client's Name
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**Contact Information (Email & Phone Number)
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**City, State, County
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**Brief Description of Needs
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**Previous Services Used (If Any)
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**Preferred Method of Communication
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**Availability for Follow-up
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**Any Urgent Issues to Address
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**How Did You Hear About Us? (Ex. social media, word of mouth etc.)
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Have You Signed The Required Non-Disclosure Agreement on the Foundation Website? (application cannot be accepted until the NDA is signed)
*
Yes
No
Submit
Should be Empty: