MADD Talent Outreach Client Intake Assessment Form

MADD Talent Outreach Client Intake Assessment Form

(708)-602-5366 | Maddtalent.vi@gmail.com
Welcome, thank you for taking the time to complete this intake form. We understand that sharing personal information can be difficult. We only ask for information that helps us to provide services, ensure your safety, and meet our program's requirements. You may choose not to answer any questions that make you feel uncomfortable unless it is required for program eligibility. Your information will be kept confidential in accordance with applicable laws and program policies.
Client Information
Name:

First NameLast Name
Preferred Name:
Pronouns (optional):
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What is your gender identity:

Other
Primary Language:
Martial Status:

Other
Safe Contact Information (Your safety is important to us. Please provide only contact information that is safe for our staff to use. If there are any restrictions on how or when we may contact you please let our case manager know.)
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
Is it safe to call/text/leave a vociemail/or email?
Other
What is your preferred and safest method of contact?

Other
Is there a specific day or time that you would prefer us to contact you?
Emergency Contact
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is it safe to contact this person?
Under what circumstance may we contact this person?
Mailing/and or Current Street Address
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this your primary address?
Is this a safe address?
Referral Information
How did you hear about our program?

Other
Demographic

The following demographic questions helps us better understand the individuals and families we serve and provides information to our programs funding. Providing this information is voluntary unless otherwise required for program eligibility. Your responses are kept confidential in accordance with our privacy policies and applicable laws.
Which Race/Ethnicity best describe you, select all that apply:

Other
Do you have any disabilities?
Are you a veteran?
Victimization Information

We understand that the following questions are a sensitive topic and can be overwhelming.We only ask the following questions below to determine eligibility for services and better understand how we can support you. Please share only what you feel comfortable sharing today.
Type of crime experienced (check all that apply):

Other
When did the crime occur?
Is the victimization ongoing?

Other
Are there any current safety concerns that you have?
Safety Questions

Immediate Safety - Your safety is our priority. The following questions help us understand whether there are any immediate concerns and how we best support you.
Are you in immediate danger?

Other
Do you feel safe where you are currently staying?
Do you need emergency assistance today?
Would you like to speak to someone today about your safety?
Is it safe for us to contact you using the contact information you provided us?
Housing Information
What is your current living situation?
If you are homeless or in unsafe housing please list below for how long:
Do you have any children?
Will you be needing housing for you and your children?

If so, can you please list below their names, age, gender, and date of birth:

Rows	Name	Gender	Age	Date of Birth
1
2
3
4

Please tell us more about your housing situation and immediate needs:

If you would like, please briefly describe what brought you in to our program today (optional):
Is there any other important information that you feel comfortable sharing today or do you have any questions regarding our program services?

Client Acknowledgement and Confidentiality
I understand that the information I provide on this intake form is used to determine my eligibility for services,develop an appropriate service plan, and meet applicable program requirements.
I understand that my personal information will be kept confidential and will only be shared as permitted or required by law, with my written authorization, or as necessary to provide services. I understand that there are limited exceptions to confidentiality, including situations involving mandated reporting requirements, court orders, or when there is a serious and imminent risk of harm to myself or others.
I acknowledge that I have had the opportunity to ask questions about this form and the services available through the program. To the best of my knowledge, the information I have provided is true and complete.
Client Signature:
Printed Name:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Case Manager Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Thank you for completeing this intake form. We appreciate you taking the time to provide this information. Our team will carefully review your application to determine eligibility for our program. We will contact you as soon as possible regarding next steps. Thank you for your patience.
Should be Empty:

MADD Talent Outreach Client Intake Assessment Form

Client Information

Emergency Contact

Mailing/and or Current Street Address

Referral Information

Demographic

Victimization Information

Safety Questions

Housing Information

Education & Employment

Program Resources and Supportive Services

Client Acknowledgement and Confidentiality