Intake Form
Date Form Completed
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Preferred Name
Parent/Caseworker/Guardian's Name
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Phone Number
*
-
Area Code
Phone Number
What is the best time of day to reach you?
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Can we send you mail?
*
Yes
No
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Gender
*
Female
Gender Queer/Gender Non-Conforming
Male
Not Listed
Prefer Not to Answer
Trans Male/Trans Man
Trans Female/Trans Woman
Race
*
Ethnicity
*
Hispanic/Latino
Non Hispanic/Latino
Living Status
Independent
With Spouse
With Relatives
Residential Facility
Homeless
Hospital
Other
Marital Status
Divorced
Married/Living Together As Married
Single
Separated
Widowed
Other
Tobacco Use
User
Non-User
Primary Language
Military Status
Yes
No
Employment
Full-Time
Part-Time
Unemployed (Not Looking for Work)
Unemployed (Actively Looking for Work)
Highest Level of Education Completed
Annual Household Income
Number of Individuals in Household
Household Members Under 18
Insurance Information
*
Uninsured
Medicaid
Medicare
Private
Insurance Company
Insurance ID Number
What brings you to North Community Counseling Centers?
*
If an earlier appointment becomes available, would you like us to contact you?
*
Yes
No
Do you have the ability to receive services electronically (e.g. telehealth services, video appointments, etc.)?
*
Yes
No
Submit
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