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HHAH InTake Sheet
Name
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Last
DOB:
(Required)
MM slash DD slash YYYY
Social Security Number:
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Race:
(Required)
US Citizen?
(Required)
Yes
No
Phone Number:
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Emergency Contact Number:
(Required)
Marital Status:
(Required)
Single
Married
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Other
Highest Level of Education:
(Required)
Employed?
(Required)
Yes
No
Veteran?
(Required)
Yes
No
If yes, please list years of service and discharge status:.
(Required)
Housing Status:
(Required)
Shelter
Street Homelessness
Residing with family and friends
Housed
If applicable, most recent address:
(Required)
Primary Medical Concern(s):
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Primary Medical Concern(s):
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Referring Medical Facility and Contact Number:
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Vital Documents Needed:
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SS Card
Birth Certificate
Identification Card
Permanent Resident
Type of Income:
(Required)
No Income
SSI/SSDI
Employment
Other
Core Service Agency:
(Required)
Core Service Agency Phone Number:
(Required)
Core Service Agency Address:
(Required)
Case Manager:
(Required)
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