Action Toward Independence

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Intake Form

Date: *

YYYY

First Name: *

Middle Initial:

Last Name: *

Home Phone:

Cell Phone:

Other Phone:

Emergency Contact Name: *

Emergency Contacts Relationship to You: *

Emergency Contact Phone Number: *

Address: *

City: *

State: *

Zip Code: *

County: *

Is your mailing address the same as your physical address? *

Yes

If not, what is your mailing address?

Email address:

Date of Birth: *

YYYY

Are you a veteran? *

Yes

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

If no, would you like to register?

Yes

Clear selection

I give Action Toward Independence permission to leave a detailed message on my voicemail/answering machine. *

Yes

Do you feel safe? *

Yes

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? *

Date of onset of disability? *

If not known, please estimate.

YYYY

What type of assistance are you looking for? *

(Anger management, Parenting, housing, employment, etc.)

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