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2223
Healthy D.M.V. ~ CV-19 Rescue
Intake Form
Advocate Partner & Organization's Name
*
Date
*
Name
*
Email
*
Last Address lived at
when, and for how long?
occupation
income source
past work history & date
salary
date of birth
medical coverage
Yes
No
provider
food stamps
Yes
No
Food Stamp amount
date rec'd.
education level completed
computer experience
Yes
No
trade(s)
certifications/licenses
list software knowledge
Driver License Number & State
I.D. Number & State
birth certificate state
probation
Yes
No
parole
Yes
No
terms
list continuing education
goals
children
Yes
No
ages and gender
spouse's name
schools attended
highest grade completed
current address
contact phone number
Reason for current living circumstance
Are interested in having a Flu vaccine or any others?
Do you currently have any medication concerns?
Do you currently have any physical ailments?
Is there currently a medical, legal, emotional, or other situation that you need immediate assistance with?
RELIGION?
request PRAYER VISITS?
Yes
No
request WOMAN WELLNESS?
Yes
No
DOMESTIC VIOLENCE circumstance?
Yes
No
DEPRESSION
Yes
No
Suicide
Yes
No
SMOKER?
Yes
No
What kinds of activities do you like doing?
Do you have any hobbies?
Registered to vote where?
Party?
How often are you able to be active?
Church attended?
Active In Sports?
Yes
No
Type of sport (if applicable)
Support Group attended?
enrolled in Therapy?
Yes
No
Type of therapy (if applicable)
Are you social?
Yes
No
How? Why not? (if applicable)
Emergency Point of Contact Information:
Name & Relationship
Address
Health care team of professionals
Name/Title/Occupation
Name/Title/Occupation
Name/Title/Occupation
*
Phone
Phone
Phone
Phone
Diagnosis
Is there currently a situation that you need immediate assistance with?
How do you handle stress?
How often are you lonely or feeling sad?
What do you do to feel better?
Have you ever considered suicide?
Yes
No
When? (if applicable)
Why?
How can I help?
Anybody you know ever felt suicidal?
Yes
No
Who? (If applicable)
What is the most important thing to you?
Last 4 social security numbers
Printed name
Date
Date
Upload file
Access Help Line Referral Info?
(844) 549-4266
I consent to the following personal information being collected on my behalf by Healthy D.C. & Me Leadership Coalition for the sole purpose of helping me to find mental wellness, employment, social service, medical, and other resources in order that I can change my current life circumstance for the better. I release and hold harmless Healthy D.C. & Me Leadership Coalition, its affiliates and representatives from any future claims that may arise as a result of their intent to advocate on my behalf.
*
I consent
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