Hillhaven Community Outreach New Visitor Intake Form.Online Logo

  • Hillhaven Community Outreach

    New Visitor Intake Form

  • Personal Information

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  • Demographics

  • Employment



  • Housing

    (Optional)

  • Requested Service(s)

    Please answer these questions based on the service(s) you are seeking during your initial visit.

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  • Acknowledgement

    I understand that Hillhaven Community Outreach is a non-profit resource/referral organization and that the information I have provided will be used for the sole purpose of providing and locating services that I have requested. I understand that Hillhaven Community Outreach will take the appropriate measures to securely store my confidential information and will not release that information to any third parties without my consent. I understand that some services will be provided by entities that partner with Hillhaven Community Outreach within my county and surrounding areas and that those referrals will only be made by Hillhaven Community Outreach with my verbal and/or written consent. I acknowledge that the information I have provided is accurate to the best of my knowledge and that assistance/services rendered is contingent upon my submission of accurate information. Hillhaven Community Outreach has the right to refuse service/assistance to anyone and failure to provide accurate information which allows them to maintain accuracy and safety for all within the organization may be grounds for refusal of further assistance/service.
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  • You MUST print and sign your name in front of staff personnel. Please DO NOT print or sign your name at this time. Read the remaining instructions and submit/return your form to the Front Desk or continue with your online submission. If submitting this form online, you will be required to sign your form once your in-office appointment has been scheduled.

    Thank you.

  • Client Intake Form Final Submission Verification

    For Staff/Volunteer Personnel ONLY

  • This section is for Hillhaven Community Outreach Staff & Volunteer Personnel ONLY!!! **Please read the instructions below on how to submit/turn in your New Visitor Intake Form below.**

     

    Electronic Submission: If you are submitting this intake form electronically by Smartphone or Computer, please click the SUBMIT button below and notify the Front Desk of your completion. If no one is at the front desk, please take a seat in the lobby until someone is available to assist you further. 

    Paper Submission: Please return your form and  your pencil/pen to the executive secretary at the front desk. If no one is at the front desk, please take a seat in the lobby until someone is available to assist you further.

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