Intake Application
Please complete the following confidential intake application to the best of your ability. If you have any questions, comments or concerns, please contact a member of the the clinic staff & someone will be glad to assist you.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurace provider name and member ID number:
Are you an active duty member or veteran of the United States armed forces?
*
Yes
No
Are you an immediate family member of an active duty or veteran of the armed forces or first responder?
Yes
No
Do you identify with the LGBTQIA2S+ community? (This is for demographic and grant writing purposes only. Again all information provided is strictly confidential.)
*
Yes
No
Please give a detailed statement of the consumer's current situation. One line statements will not be accepted.
*
What has the consumer done in the last 180days (six months) to help their situation? Whathas worked for them and what has not workedfor them. *Leaving this space blank will impacteligibility for consideration of approval to ourprogram.
*
How can we assist you today?
*
Housing
Employment
Transportation
Benefits
Other
Please click here to review our Consumer Handbook. you will be required to sign below that you have read, understand and agree to the terms and conditions of our programs and services.
Do you agree and understand the Service Agreement outlined in the Consumer Handbook .
*
I agree
If available, please upload a copy of your Driver license, state issue ID, military ID, Green Card, Visa, DD-214.
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Signature: By affixing your signature below you are confirming that all information provided is true and correct to the best of your knowledge.
*
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