Intake Form
AHI Client Intake Form
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Legal First Name *
Legal Last Name *
Birthdate *
MM
/
DD
/
YYYY
Are you? *
Email *
Street Address *
City, State, Zip Code *
Phone number *
Household Size Including Yourself *
Languages you speak *
Required
Immigrant/Refugee Status (Optional)
Clear selection
Year Entered in the United States
Clear selection
What is your Occupation? / Job Title *
Highest Level of Education in Home Country *
Highest Level of Education in United States *
Do you receive public benefits? (TANF/SNAP/Food Stamps/ WIC etc) *
Do you receive or have your received unemployment benefits due to COVID-19 in 2020. *
How would you describe your health? *
What resources, programs, and services would you like to see Afghan Health Initiative Provide for the Afghan Community? *
Which of the following services from AHI do you need/are interested? *
Required
Any other comments, questions, or concerns?
Case Notes
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