Client Intake Form
Before you can access PCS Family services, we need you to fill out the intake form. Please fill it out to the best of your abilities, and when you come visit us in person, someone will follow up with you about any questions you were unable to answer.
Name (First and Last) *
Your answer
Email *
Your answer
Street Address *
Your answer
City
Your answer
Zipcode
Your answer
How long have you lived at your current address?
Your answer
Primary Phone number
Your answer
Secondary Phone number
Your answer
Sex
Which of the following documents have you submitted to Project Caring and Sharing?
Date of Birth
MM
/
DD
/
YYYY
Place of Birth
Your answer
Race
Your answer
Marital Status
Your answer
Do you have children?
If yes, please list their names and ages
Your answer
Are you receiving child support?
Do you need childcare services?
Your answer
What is the children or child's current residence?
Your answer
Is the residence above the children or child's permanent residence?
Which of these describe your residence for the past year?
What is your source of financial support?
Your answer
Have you ever been arrested?
If yes, please describe what you were arrested for and list corresponding dates:
Your answer
Have you ever been convicted of a crime?
If yes, please describe the nature of the offenses and list corresponding dates:
Your answer
Have you ever been in jail?
Have you ever been in prison?
What is your prison ID number?
Your answer
What was your release date?
MM
/
DD
/
YYYY
How many times did you go to jail or prison as a juvenile?
Your answer
How many times have you been to jail or prison as an adult?
Your answer
How much time have you spent incarcerated as an adult?
Your answer
Are you currently on probation?
Are you currently on parole?
If you answered yes to either of the past two questions, how long is your probation or parole?
Your answer
If you are on probation or parole, what is the name of your agent (First Last)
Your answer
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