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Action Toward Independence
Intake Form
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* Required
Date:
*
MM
/
DD
/
YYYY
First Name:
*
Your answer
Middle Initial:
Your answer
Last Name:
*
Your answer
Home Phone:
Your answer
Cell Phone:
Your answer
Other Phone:
Your answer
Emergency Contact Name:
*
Your answer
Emergency Contacts Relationship to You:
*
Your answer
Emergency Contact Phone Number:
*
Your answer
Address:
*
Your answer
City:
*
Your answer
State:
*
Your answer
Zip Code:
*
Your answer
County:
*
Your answer
Is your mailing address the same as your physical address?
*
Yes
No
If not, what is your mailing address?
Your answer
Email address:
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Are you a veteran?
*
Yes
No
Gender:
*
Male
Female
Ethnicity:
*
Hispanic/Latino
Other
I prefer not to disclose
Race:
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
I prefer not to disclose
Marital Status:
*
Single
Married
Divorced
Widowed
I prefer not to disclose
Housing Status:
*
Assisted living
Independent
Homeless
Dependent living with family or friends
Institution
Other
Employment Status:
*
Full time
Part time
Looking for a job
Unemployed, not seeking work
Student or training program
Retired
Segregated work or day program
Other
I prefer not to disclose
Last School Completed:
*
Pre-K
K-8
Some high school
Completed high school
Some college
Business/Trade/Vocational school
2 year undergrad degree
4 year undergrad degree
Post graduate degree
Unknown/Not yet enrolled
Are you registered to vote?
*
Yes
No
If no, would you like to register?
Yes
No
Clear selection
I give Action Toward Independence permission to leave a detailed message on my voicemail/answering machine.
*
Yes
No
Do you feel safe?
*
Yes
No
Please check any COGNITVE disabilities that apply:
Intellectual disability
Traumatic & other brain injuries
Learning disability
Autism
Other cognitive disabilities
Please check any MENTAL/EMOTIONAL disabilities that apply:
Mental illness
Emotional/behavioral disabilities
Substance abuse
Other mental illnesses
Please check any PHYSICAL disabilities that apply:
Spinal cord injury
Neuromuscular
Orthopedic
Cerebral Palsy
Spina Bifida
Other congenital birth anomaly
Epilespy
Muscular Dystrophy
Amputation
Back injury
HIV/AIDS
Environmental/other related illnesses
Please check any SENSORY disabilities that apply:
Blindness
Low vision
Deafness
Hard of hearing
Other sensory disabilities
What is your primary disability?
*
Your answer
Date of onset of disability?
*
If not known, please estimate.
MM
/
DD
/
YYYY
What type of assistance are you looking for?
*
(Anger management, Parenting, housing, employment, etc.)
Your answer
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