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Name ( First / Last)
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Preferred Name
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Email Address
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Date of Birth
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SSN
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ID#
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Intake Form
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Income (FPL):_______%
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Cisgender: I DO identify with birth gender
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Transgender: I DO NOT identify with birth gender
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Gender Identity
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Sexual Orientation
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Ethnicity/Race
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Mother’s Maiden Name
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Phone Number
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Voicemail/Text Okay?
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Address (Street No., Street Name, City, State, Zip)
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Current Status
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Current Living Situation
• • •
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If Other, specify
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Do you struggle to access food regularly?
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Is transportation a barrier for you?
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Do you usually feel safe in your day to day?
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Do you have access to a doctor/primary care provider?
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When was your most recent appointment?
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Do you have access to a mental healthcare provider?
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When was your most recent appointment?
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What has prevented you from seeking mental health services?
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Over the last 2 weeks have you been bothered by any of the following?
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Feeling anxious or on edge
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Constant worrying
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Feeling depressed or hopeless
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Little interest in doing things
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Signature
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Date
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