Client Service Intake

Who is completing this form?*
Relationship to Client
Your Full Name

First NameLast Name
Your Primary Phone #
Your E-mail
Preferred contact method

PhoneTextEmail
Interpreter needed
Preferred Language

EnglishSpanishFrenchOther

Client Information
Client Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemaleNon-binaryPrefer not to say
E-mail*
example@example.com
Primary Phone #*
Current Living Situation*
Primary Diagnosis / Support Needs (brief)

Providers, Insurance & Referrals
Primary Care Provider (PCP) Name
PCP Phone / Clinic
Referring Provider
Insurance Type

Medicaid (KanCare)MedicarePrivateSelf-PayUnknown

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

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