Client Service Intake

Timing & Next Steps
How soon do you need services?*
Best time to contact you*

MorningAfternoonEveningWeekend
Preferred Contact Person*

ClientPerson Completing FormCase Manager
HIPAA/Privacy Notice

Information submitted is used only to coordinate services and will be protected in accordance with HIPAA and KDADS guidelines.
Electronic Signature (Client or Legal Representative) *

Clear
Signer's Full Name*
Relationship to Client
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty: