INTAKE FORM Complete the form below, or click here to download this form to submit offline (it is a fillable Word document). Referral Date* Date Format: MM slash DD slash YYYY Are you referring:*yourselfsomeone elseYour Name* First Last Referral SourcePreferred follow up method: E-mail Phone Text Letter Name* First Last Date of Birth Date Format: MM slash DD slash YYYY Ethnicity Hispanic Caucasian African American Pacific Islander Asian American Indian SexMFSocial Security #Marital StatusSingleMarriedSeparatedWidowedDivorcedEmail PhoneCurrent Residence Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Type of Residence Emergency Shelter Hospital (psychiatric or medical) Rental/Owned Property Detox Center Jail/Detention Center Family/Friends House Place not meant for habitation Hotel/Motel (without voucher) Currently Homeless?YesNoAt risk of losing current housing?YesNoIf Yes, reason at risk of losing current housing?Military InformationBranch of ServiceService Dates Date Format: MM slash DD slash YYYY Military Status Active Duty Veteran Reserve Component Discharge Honorable General OTH Bad Conduct Dishonorable Other Employment & TrainingEmployment Status Employed Unemployed Disabled Retired Student Valid Drivers License?YesNoLic. #State IssuedIncomeWhat is Your Total Monthly IncomeSources of Cash Benefits Job Disability Unemployment State Assistance Pension Sources of Non-Cash Benefits SNAP (Food Stamps) WIC Child Care Services Other LegalHave you been convicted of a crimeYesNoPending charges?YesNoHealthMental Health History?YesNoMental Health DiagnosisMedical Health History?YesNoMedical Health DiagnosisSubstance Use History?YesNoDrug of Choice?History of Detox?YesNoMost recent detox locationMost recent detox date Date Format: MM slash DD slash YYYY How many times in detox?Health Insurance InformationCurrently Active Health InsuranceYesNoHealth Insurance Company Name*Insurance ID#*Service NeedsPlease mark all that apply.Housing Rental Assistance Transitional Housing Placement HUD-VASH Voucher Permanent Supportive Housing Placement Moving Assistance Shelter Placement Employment Job Training Programs Employment Opportunities Work Place Accommodations Medical Mental Health Treatment Substance Abuse Treatment Access to Medical Care Medication Access Dental Services Transportation MBTA Services VTA Services DAV Transportation Services Benefits Disability Benefits (SSI/SSDI) VA Service Connection VA Pension Former Employer Pension TAFDC EAEDC Insurance Coverage Food Support (SNAP/WIC) VA Clothing Allowance Child Care Education Scholarships Tuition Assistance Locating Schools Vocational Training Other Financial Advice Legal Aid Social Supports Other