New Client Intake Form

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Name

This field is for validation purposes and should be left unchanged.

NEW CLIENT INTAKE FORM

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Pronouns:

ie: She/her, He/Him, They/Them, She/He, She/They, He/They, Xe/Xem, It/Its, Other

What City/Town Do You Live In?(Required)

Gender:

Female

Male

Transgender

Other

Unknown/Not Reported

Nonbinary

Questioning

Preferred way to be contacted:(Required)

Home Phone

Mailing Address

Cell Phone

Home Phone #:(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone #:(Required)

Email:(Required)

Brief Description of Need:

I consent to give Action Inc. staff permission to share my personal information internally within Action Inc. to its programs, and to report my personal information to the entities that fund, audit, or evaluate Action Inc. programs as may be required. I understand that Action Inc. will maintain the confidentiality of personal and financial information I provide about myself and my family members receiving services from Action Inc., except that Action Inc. may share that information within Action Inc. as necessary to provide services to me and to administer its other programs. Action Inc. may disclose information as required by or upon request of government agencies and other entities that fund, regulate, audit, monitor, or investigate Action Inc., and as authorized or required by law, legal process, or court order. For any other purpose, Action Inc. will only disclose information with my written consent.(Required)

Yes, I consent

DEMOGRAPHIC INFORMATION

Primary Language:

Secondary Language:

Marital Status:

Translator Needed:

Yes

Disabled:

Yes

Disconnected Youth: (age 14-24 years old who are not working nor in school)

Yes

Ethnicity:

Race:

Education Level:

Military Status:

Employment Type:

Pregnant:

Yes

Due date:

How did you hear about Action Inc.?:

HOUSEHOLD INFORMATION

Family Type:

Living Situation:(Required)

Housing Type:

Heating Type:

Is your heat included in your rent?

Yes

N/A

INCOME

Do you receive any income? Income can include wages, SSDI/SSI, TAFDC, etc.

Yes

Income Type #1:

Income amount and payment frequency?

(i.e., $400/month)

Income Type #2:

Income amount and payment frequency?

(i.e., $400/month)

Income Type #3:

Income amount and payment frequency?

(i.e., $400/month)

Income Type #4:

Income amount and payment frequency?

(i.e., $400/month)

BENEFITS

Benefits Received (Please select all that apply):(Required)

Affordable Care Act Subsidy

Chapter 115 Veterans’ Benefits

Childcare Voucher

EAEDC

Fuel Assistance (LIHEAP)

HomeBASE

HUD-VASH

Public Housing (NOT Section 8)

Section 8/Housing Choice Voucher

QUEST Voucher

SNAP

SSDI

SSI

State Supplement

TAFDC

WIC

Other Permanent Supportive Housing

None

EXPENSES

**Expenses include rent and mortgage payment, utilities, phone bill, etc.**

Household Expense #1:

How much do you pay and how often?

(i.e., $800/month)

Household Expense #2:

How much do you pay and how often?

(i.e., $800/month)

Household Expense #3:

How much do you pay and how often?

(i.e., $800/month)

Household Expense #4:

How much do you pay and how often?

(i.e., $800/month)

Do you have health insurance?

Yes

Insurance Type:

CHIP

Employment Based

Medicare

Private Health Insurance/Direct Pay

ConnectorCare

Medicaid/MassHealth

VA/Military Health Care

Other

Unknown

HOUSEHOLD MEMBERS

Does anyone else live with you?(Required)

Yes

Number of Other People in Your Household (Not Including You):(Required)

Full Name:

Other Household Member #1

Date of Birth:

MM slash DD slash YYYY

Gender:

Full Name:

Other Household Member #2

Date of Birth:

MM slash DD slash YYYY

Gender:

Full Name:

Other Household Member #3

Date of Birth:

MM slash DD slash YYYY

Gender:

Full Name:

Other Household Member #4

Date of Birth:

MM slash DD slash YYYY

Gender:

Full Name:

Other Household Member #5

Date of Birth:

MM slash DD slash YYYY

Gender:

Full Name:

Other Household Member #6

Date of Birth:

MM slash DD slash YYYY

Gender:

Full Name:

Other Household Member #7

Date of Birth:

MM slash DD slash YYYY

Gender: