Action Toward Independence
Intake Form
Date: *
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First Name: *
Middle Initial:
Last Name: *
Home Phone:
Cell Phone:
Other Phone:
Address: *
City: *
State: *
Zip Code: *
County: *
Is your mailing address the same as your physical address? *
If not, what is your mailing address?
Email address:
Date of Birth: *
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Are you a veteran? *
Gender: *
Ethnicity: *
Race: *
Marital Status: *
Housing Status: *
Employment Status: *
Last School Completed: *
Are you registered to vote? *
If no, would you like to register?
Clear selection
I give Action Toward Independence permission to leave a detailed message on my voicemail/answering machine. *
Do you feel safe? *
Please check any COGNITVE disabilities that apply:
Please check any MENTAL/EMOTIONAL disabilities that apply:
Please check any PHYSICAL disabilities that apply:
Please check any SENSORY disabilities that apply:
What is your primary disability? *
Date of onset of disability? *
If not known, please estimate.
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What type of assistance are you looking for? *
(Anger management, Parenting, housing, employment, etc.)
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