Intake Form

WEST MICHIGAN ASIAN AMERICAN ASSOCIATION INTAKE FORM
Personal Information
Full Legal Name

First NameLast Name
Age
Gender
Phone Number

Area CodePhone Number
Email Address
Preferred Contact Method
Address

Street Address

Street Address Line 2

CityState

Zip Code
Demographic Information
Race/Ethnicity
Number of years in United states
Household Information
Number of people reside in household
How many children reside in your house and their school district/grade:
Employment Status
Employment status
Services
Identify area(s) that you need support
Other (Please explain)
Tell us more details about the services you need
Tell us a little about yourself. What you like to do, your hobbies, and dreams/goals.
How did you hear about WMAAA ?
Did you complete this form yourself, or was it completed by someone else on your behalf? If it was completed by another Person, Please enter their name and relationship to you?
Signature of the Person who helped you complete this form. By signing, they agree to the organization's privacy policy and confidentiality requirements.
Are you Referred to WMAAA by any other Organization?
Contact Person in Referral Organization
We respect your privacy and will keep any personal or health-related information you provide confidential. If you provide health information, it will be handled in a manner accordance with HIPAA privacy principles. Your information may be shared with referral organizations only with your consent or as required by law or to address safety concerns. By submitting this form, you consent to the use of your information as described above.
Consent & Signature
I confirm the information I have provided is accurate, and I give permission for WMAAA to use it to support me and determine my eligibility for services
Date

MonthDayYear
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WEST MICHIGAN ASIAN AMERICAN ASSOCIATION INTAKE FORM

Personal Information

Demographic Information

Household Information

Employment Status

Services

Consent & Signature