Command Identity Intake Application
Please complete this form to help us understand your needs and determine the best support services for you.
SECTION 1: Personal Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Medicaid Provider
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Eligibility Status
SECTION 2: Current Support & Legal Status
Are you currently receiving any support or services?
Please Select
Yes
No
If yes, please describe the support/services you receive.
Are you currently incarcerated?
Please Select
Yes
No
Have you been sentenced?
Please Select
Yes
No
When is your next court date?
-
Month
-
Day
Year
Date
What were your criminal charges?
How many times have you been convicted of a crime?
Do you need transitional housing?
Please Select
Yes
No
Do you need a letter of recommendation for court?
Please Select
Yes
No
Do you have employment?
Please Select
Yes
No
Are you actively seeking employment or entrepreneurship opportunities?
Please Select
Yes
No
SECTION 3: Goals & Interests
What skills or talents do you possess?
Highest level of education:
Please Select
Less than high school
High school diploma / GED
Some college
Associate degree
Bachelor’s degree
Master’s degree
Trade/Certification
Other
What area are you most interested in developing?
Do you have special needs or accommodations?
Please Select
Yes
No
If yes, please describe your accommodations.
Are you currently enrolled in any educational programs?
Please Select
Yes
No
If yes, please specify the program.
Do you feel confident in your basic reading, writing, or math skills?
Please Select
Yes
No
If no, what areas would you like to improve?
SECTION 4: Life Skills & Daily Living
How comfortable are you with managing daily responsibilities such as cooking, cleaning, and time management?
Please Select
Very comfortable
Somewhat comfortable
Not comfortable
Do you have experience with setting and achieving personal goals?
Please Select
Yes
No
Are you familiar with basic problem-solving and decision-making skills?
Please Select
Yes
No
Do you need support with communication and conflict resolution?
Please Select
Yes
No
SECTION 5: Mental Health
Do you take medication?
Please Select
Yes
No
If yes, what medication do you take?
When was your last mental health evaluation?
-
Month
-
Day
Year
Date
Do you have any mental health or behavioral concerns that should be addressed?
Please Select
Yes
No
If yes, please describe.
SECTION 6: Emergency Contact
Emergency Contact Full Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to You
Submit
Should be Empty: