OHL Client Intake Form

Open Heart Leaders Client Intake Form
Client Information

Please fill out a separate intake form for each person being served by Open Heart Leaders. All information collected is confidential. Your information is not sold or shared to any third party agencies. Applicants under 12 years of age must have a guardian or parent complete the complete form.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Please enter a valid phone number.
Additional Number
Please enter a valid phone number.
Email*
example@example.com
Additional Email
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMalePrefer Not To SayOther
Ethnicity*
Education*
Primary Language*
LIFE Sector (Please select all that apply)*

Mentoring Program (Ages 14 - 18)CoachingCounseling (General counseling ages 5 & Up for Individual, Family or Couples)ResourcesN/A
Reform Sector (Please select all that apply)*

Counseling (for those who were formally incarcerated who may meet the program specific criteria)N/A
Build Sector (Trainings and Workshops are based on schedule and availability, please check website calendar for upcoming dates)*

TrainingWorkshopN/A
Educate Sector (Please select all that apply)*

Community Resource Education Support Team (C.R.E.S.T.)Heart Leaders Academy (Accredited High School Program for ages 15 - 29+)N/A
Referral Program (Who referred you to Open Heart Leaders?)*

JDI ProgramUrban CorpsCRD (Community Resource Directory)ProbationParoleCare SolaceSchool ReferralCommunity PartnerN/AOther Not Listed (Type Here)
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Relationship to Applicant*
The remainder of the client intake form is a questionnaire that allows our agency to collect data and provide appropriate services and care. Please answer the following questions honestly to the best of your knowledge.
Household Size (How many people are in your home including you)*
What is your Household Income*

Less than $10,000$10,000 to $29,999$30,000 to $49,999$50,000 to $79,000More than $80,000Choose Not To Answer
Are you currently seeking employment?

YesNo
Student Status - Are you a student?

Yes, Full-TimeYes, Part-TimeNo
Are you or a member of your household participating in any of the following services or programs? (please check all that apply).*

CALFreshWelfareMedi-CalMedicare (Individuals 65+)Section 8Public or Subsidized Housing AssistanceN/A
What is your primary mode of transportation to get to Open Heart Leaders?

CarPublic Transportation (Bus, Trolley, Train, etc.)BicycleWalkingOther
How did you hear about Open Heart Leaders?

Family or FriendOther OrganizationFacebookTwitterInstagramLinkedInOther
Contact Record Type Id
Should be Empty:

Open Heart Leaders Client Intake Form

Client Information

Emergency Contact Information