Client Intake Form

Are you receiving any help or support with completing this form?

Yes

No

If yes, please provide the name of the person assisting you with this form and their relationship to you/the client.

Client's First Name

Client's Last Name

Email

Contact Phone

When is the best time to reach you?

Morning (8 AM – 12 PM)

Afternoon (12 PM – 4 PM)

Evening (4 PM – 8 PM)

Anytime

Multi-line address

Country/Region

Address

City

Zip / Postal code

Date of Birth

Month

Day

Year

Race/Ethnicity?

Gender / Sex

Male

Female

Other

Marital Status

Single

Married

Other

Living Arrangement

Alone

With Someone

If the client lives with someone, please specify their relationship (e.g., spouse, parent, friend, caregiver).

Are you a NC Medicaid recipient?

Yes

No

If yes, please list your Medicaid ID# for eligibility verification.

Have you seen your primary care physician within the last 90 days?

Yes

No

Unsure

Name of Primary Care Physician:

Primary Care Physician Phone Number:

What is the name and number of your emergency contact person?

Is there anything else you'd like for us to know...

Upload Documents

How did you hear about us? (Select all that apply)

By checking this box, you confirm that you are 18 years of age or older and give us permission to contact you/the client.