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Community Engagement  Intake Form
Youth Care LLC
2806 Courthouse Road 
Virginia 23860
Confidential- For Internal Use Only
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Full Name *
Email *
Home Address *
Date of Birth *
Social Security Number *
Medicaid Number *
(Emergency Contact) Name
(Emergency Contact) Relationship
(Emergency Contact) Phone Number
(Guardian Representative) Name
(Guardian Representative) Phone Number
(Guardian Representative) Legal Authority *
Required
Living Arrangement *
Required
(Living Arrangement) Residential Provider Name (if applicable)
(Living Arrangement)  Primary Contact at Residence
(Living Arrangement)  Phone Number
(Medical Information) Primary Care Physician
(Medical Information) Primary Care Physician Phone Number
(Medical Information) Allergies (If any)
(Medical Information) Current Medications
(Medical Information) Mobility Needs
(Service Needs & Goals) Areas of Support Requested (Check all that apply)
(Service Needs & Goals) Short-Term Goals
(Service Needs & Goals) Long-Term Goals
(Support Team Information) Case Manager Name
(Support Team Information) Agency
(Support Team Information) Agency Phone Number
(Support Team Information) Agency Email
(Support Team Information) Behavioral Therapist Name (If Applicable)
(Support Team Information) Behavioral Therapist Phone Number (If Applicable)
I authorize Youth Care LLC to provide Day Support services as
outlined in my individualized service plan. I also consent to the collection and sharing of
relevant information with authorized providers to ensure quality and coordinated care.

Client/Guardian Signature:
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