Client Intake Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Full Name *FirstLastStreet Address: *City, State, Zip Code *Date of Birth *ex: 01/01/1970Phone number *Example: 239-936-4318Email Address *What is your psychiatric diagnosis *What is your annual household income *Are you on disability benefits due to a psychiatric condition? *YesNoDo you receive Supplemental Security Income (SSI) *YesNoDo you receive Social Security Disability (SSDI) *YesNoApplying or have appliedDo you have an application or appeal for Social Security or VA benefits in process? *YesNoDo you have a court appointed legal guardian? *YesNoDo you have a resource coordinator or case manager *YesNoAre you a member of a FACT team or CASL *YesNoDo you receive straight Medicaid or Medicaid Share of Cost *YesNoDo you receive Medicare or Medicare supplemental insurance? *YesNo Email guardian? Income Do you receive Veteran's benefits? *YesNoDo you have private medical insurance? *YesNoNote: If you have private health insurance, you may not qualify. Eligibility may be considered only if your healthcare premiums are $0What aspects of your mental wellness need to change in order to begin working or volunteering *Are you able to access the supports and services you consider most helpful for your mental wellness if not what needs to change *What kind of work or volunteering would you like to do *What if any physical limitations do you have that affect the type of work or volunteering you want to do *How would you like your social life to be *How would you like your living situation to be *How would you like your financial situation to be *Type in your Full Name *Typing your full name here counts as your electronic signatureDate completed: *Preferred Coach *Janelle, Leslie, Maria, or first available Office Use OnlyDate application was received and Manager initialsSubmit
