PELAGIE FOUNDATION – UNIVERSAL INTAKE FORM
Empowering Wholeness Through Integrated Care
1. Client Information
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
Prefer not to say
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Preferred Method of Contact
*
Phone
Text
Email
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2. Emergency Contact
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Relationship to Client
*
3. Service Interest
Check All That Apply
*
Housing Assistance
Case Management
Mental Health Counseling
Chaplaincy / Spiritual Support
Medical / Telehealth Services
Workforce Development / Job Search
Hair Salon / Cranial Prosthesis Services
Veteran Support
Other
4. Health & Social Background (Optional if not clinical)
Do you have any current medical or mental health concerns?
Yes
No
If yes, please describe:
Are you a:
*
Please Select
Veteran
Domestic Violence Survivor
Person with HIV/AIDS
Currently Homeless
Receiving Public Assistance (SNAP, TANF, etc.)
5. Wholeness Process Acknowledgment
At the Pelagie Foundation, we are committed to providing comprehensive, integrated care through our Wholeness Process. As part of your intake: A clinician and therapist will automatically follow up with you to assess your medical and emotional needs. Other departments may also reach out to offer additional support based on your situation.
By completing this form, you acknowledge and agree to Pelagie’s holistic approach to care.
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Staff Member Receiving Intake:
First Name
Last Name
Signature
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