BOOST ~ Client Intake Form

BOOST ~ Client Intake Form
Date*

MonthDayYear
Date
Legal Name*

First NameLast Name
Preferred Name
Gender*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
How did you hear about us?*
Please Specify*

Members of Household

	Name	Birthdate	Gender	Age
Significant Other
Child
Child
Child
Child
Child
Child
Child

Emergency Contact *
Name
Relationship to Client*
Phone Number*
Please enter a valid phone number.

Consent for BOOST Screening
I understand that participation is voluntary and I may withdrawn at any time, though actions already taken cannot be revoked. I hearby consent to participate in the BOOST screening.
Full Name
Signature

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Date*

MonthDayYear
Date
Hour MinutesAM/PM Option

Authorization for Release of Information
Authorization

I, the undersigned, hereby authorize Building Our Families (BOF) and its representatives to exchange and disclose information about me and/or my household with any agency, organization, or provider necessary to coordinate services and supports. This may include, but is not limited to

-            Child Protection Services (CPS)

-            Inter-Lake Community Action Partnership (ICAP)

-            Prairie Five Community Action

-            Housing Authorities and Landlords

-            School and Educational Programs

-            Mental Health or Medical Providers

-            Law Enforcement of Court Systems

-            Community Service Organizers

The information that may be shared includes:

-            Intake and referral information

-            Case notes, progress reports, and service plans

-            Financial or housing information relevant to services

-            Other information necessary for coordinated care

Purpose of Disclosure

The purpose of this release is to allow BOF and collaborating agencies to:

-            Coordinate and provide services

-            Assist with housing, financial, medical, educational services

-            Improve communication and outcomes for the client/family
I understand...

This authorization is voluntary and that refusal to sign will not affect my ability to receive BOF servicesThis authorization will remain in effect for one (1) year from the date of signature, unless I specify and earlier expirationI may revoke this authorization at any time by notifying BOF in writing. Revocation will not apply to information already releasedI acknowledge BOF cannot guarantee that information disclosed with not be re-disclosed by the receipient, and such information may no longer be protected by law.
Full Name*
Signature

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Date*

MonthDayYear
Date
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BOOST ~ Client Intake Form

Consent for BOOST Screening

Authorization for Release of Information