2026 In-Person Intake Form

2026 In-Person Intake Form

Clallam Mosaic
Participant Name*

First NameLast Name
Gender*

MaleFemaleNon-binary
Date of Birth*

MonthDayYear
Date
Legal status(choose one)*

MinorGuardianshipIndependentOther
If you chose "other" for level of independence, please clarify
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Can we text phone?

YesNo
Phone Number
Enter a second contact number if you have one.Format: (000) 000-0000.
Can we text phone?

YesNo
Participant's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your preferred method of receiving program information:

TextEmailPaper
Living Status*

Live alone with paid care providersLive alone with family providing careLive alone, no care providersLive in group home or supported living facility with paid care providersLive in shared housing with one roommateLive in shared housing with multiple roommatesLive with familyCompanion HomeOther (Please clarify)
If you chose "other" for living status, please clarify
Is the participant's mailing address the same as the home address?*

YesNo, please fill in mailing address below
Mailing Address (Complete if different from home address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Name of Emergency Contact*

First NameLast Name
Phone - 1st Emergency Contact*
Please enter a valid phone number.Format: (000) 000-0000.
Email - 1st Emergency Contact
example@example.com
Name of Second Emergency Contact*

First NameLast Name
Phone # - 2nd Emergency Contact*
Please enter a valid phone number.Format: (000) 000-0000.
Email - 2nd Emergency Contact
example@example.com
Name of person completing form*

First NameLast Name
Signature - By signing below, the person completing this form attests that the information provided is true, accurate and complete to the best of his/her knowledge.*
To complete registration, the following forms are needed:

Filled out once for 2026
1. 2026 In-Person Intake Form
2. 2026 Health Status Form
3. 2026 Health Liability Release Waiver
4. 2026 In-Person Code of Conduct
5. 2026 Participant Consent Form
Should be Empty: