Community Care Network Intake Form

Please fill this form out accurately and honestly to help us meet your needs best.

Name *
Name
Phone *
Phone
Date of Birth *
Date of Birth
Select one.
Do you have a vehicle? *
Are you currently employed? *
Are you a U.S. Citizen? *
Emergency Contact *
Emergency Contact
Emergency Contact Phone Number *
Emergency Contact Phone Number
Are you incarcerated or in drug treatment? *
Name of Your Case Manager
Name of Your Case Manager
Case Manager Phone Number
Case Manager Phone Number
Date of Release from Jail or Guardian from Treatment
Date of Release from Jail or Guardian from Treatment
Have you ever called our agency for shelter assistance? *
Were you in the military? *
Are you the head of your household?
Are you pregnant? *
If yes, are you receiving prenatal care?
If yes, is the pregnancy high risk?
Do you or your children have any injuries now?
Have you been tested for HIV? *
If diagnosed positive with HIV, when?
If diagnosed positive with HIV, when?
Have you been tested for Hepatitis C? *
If diagnosed positive with Hepatitis C, when?
If diagnosed positive with Hepatitis C, when?
Have you been tested for TB?
If tested positive for TB, when?
If tested positive for TB, when?
Have you been tested for any other contagious or communicable disease?
If yes, when?
If yes, when?
Do you have health insurance?
Do you smoke cigarettes?
Have you used drugs or alcohol in the past year?
Are you presently attending any 12-step support program?
Please identify the drugs you have tried (Select all that apply).
Have you ever been arrested? *
Are you currently in (Please select):
If applicable, proposed release date.
If applicable, proposed release date.
Have you ever participated in drug or alcohol treatment programs while incarcerated?
Did you complete the program?
Was your participation in treatment court mandated?
Please select all that apply: I receive: *
Marital Status: (Please select one)
Name of Spouse/Partner
Name of Spouse/Partner
Spouse/Partner DOB:
Spouse/Partner DOB:
Address of Spouse/ Partner
Address of Spouse/ Partner
Date of Last Contact with Spouse/Partner
Date of Last Contact with Spouse/Partner
Have you or your spouse filed for divorce?
Are you a domestic violence victim?
If yes, name of offender.
If yes, name of offender.
Is there a protection order?
Do you believe that your abusive partner may be looking for you?
Do you feel you may be in danger
Please sign your name to affirm you answered the questions to the best of your knowledge truthfully and correctly.
Please sign your name to affirm you answered the questions to the best of your knowledge truthfully and correctly.
Date this form was completed.
Date this form was completed.