INTAKE PORTAL
Please complete this intake form to help us better support you. All information is confidential and used only for program eligibility and support.
Initiative Intake
Welcome. Please fill out the following information to the best of your ability.
Full Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Medicaid Status
Please Select
I have an Active Medicaid Card
I need to apply
I am uninsured
Medicaid ID #
NCID / State ID (Upload a clear image or PDF)
*
Upload a File
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of
Referral Source
Please Select
Court
Probation
Community
Web
Submit Intake Form
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