intake form

Healthy D.M.V. ~ CV-19 Rescue

Advocate Partner & Organization's Name

Name *

Email *

Last Address lived at *

when, and for how long? *

occupation *

income source *

past work history & date *

salary *

date of birth *

medical coverage *

provider *

food stamps *

Food Stamp amount *

date rec'd. *

education level completed *

computer experience *

trade(s) *

certifications/licenses *

list software knowledge *

Driver License Number & State *

I.D. Number & State *

birth certificate state *

probation *

parole *

terms *

list continuing education *

goals *

children *

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? *

request WOMAN WELLNESS? *

DOMESTIC VIOLENCE circumstance? *

DEPRESSION *

Suicide *

SMOKER? *

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? *

Type of sport (if applicable)

Support Group attended? *

enrolled in Therapy? *

Type of therapy (if applicable)

Are you social? *

How? Why not? (if applicable)

Emergency Point of Contact Information:

Name & Relationship *

Address *

Health care team of professionals

Name/Title/Occupation *

Name/Title/Occupation

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? *

When? (if applicable)

Why? *

How can I help? *

Anybody you know ever felt suicidal? *

Who? (If applicable)

What is the most important thing to you? *

Last 4 social security numbers *

Printed name *

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