New Client Intake & Medical History Form

Intake form

This form takes about 8-10 minutes to complete. Please make sure to complete all required fields as this information helps me to best serve your family.
Full Name

First NameMiddle NameLast NameSuffix
Preferred Name
Preferred Gender Pronouns
Birth Date

MonthDayYear
Age:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone Number

Area CodePhone Number
Is there anyone I can contact to get in touch with you?
Name of contact
Phone Number

Area CodePhone Number
What's the best way to reach you?
Race

Other
How do you Identify?

Other
How did you hear about us?

Other
Which best describes your current housing situation?”
Homeless First Time
Length of Homeless:
Which Location do you prefer to receive services
Which program are you interested in?
Resources Needed
How can we help you?

Emergency Form

Emergency Contact when participant can not be reached, list at least one person who may be contacted in an emergency or for follow up.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Relationship
In emergencies requiring immediate medical attention, you or your child will be taken to the nearest hospital emegency room. Your signature authorizes the resposible staff to transport and care of any residents at that hospital.
Participant/ Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Health and Medical History

Please share any current or past health conditions you feel we should know about to support you well. (Examples: asthma, diabetes, chronic pain, injuries, surgeries, etc.)
Medical Conditions
Food Allergies/Reactions
Medications
Other Allergies/Reactions
Emergency Medical Instructions
Full Name

First NameLast Name
Participant/ Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Intake form