Short Client Intake Form (Non- clinical)

Client Intake Form - Non-Clinical Services
Date*

MonthDayYear
Date
Client Information:
Full Name*
Age*
Race/Ethnicity Optional
Current Housing Situation:
Housed (Please specify type of housing)_________________________* Unhoused
Service(s) Requested (Please check all that apply):*

Referral ServicesClothingCommunity Care Package (food and hygiene)
Please list each child's information below or your own sizes needed. Please specify under SPECIFIC NEEDS: clothing size, type of products, or specific restrictions.*
How did you hear about our services?   Type a label*
Contact Information (Optional):
Phone Number:   Type a label*
Email Address:   Type a label*
Thank you for completing this form. A staff member will be in touch with you as soon as possible.
For Internal Use Only:
Date Received

MonthDayYear
Date
Intake Staff
Notes:
Should be Empty:

Client Intake Form - Non-Clinical Services