IntakePlease read the information above to complete the intake form. Today's Date * MM DD YYYY Initials of attending staff member (input your initials here) * Is the client/patient safe right now? * Yes No Client/patient name * Client/patient age * Client/patient gender and pronouns * Client/patient location of origin * Languages spoken by client/patient (list all in order of most fluent to least) * Client/patient's employment status * Not employed Employed Unknown (Optional) Any other relevant personal details or supports (Ex: client/patient at additional agency, has family nearby) Client/patient's goal in accessing services * Thank you! When prompted, click here to continue to the next section
