SHORT INTAKE FORM
UNIFORM REPORTING SYSTEM Page 1 of 3
Form date Sep 05
* NAME ~ PLEASE PRINT
* IDENTIFIERS
* CLIENT ID: * LAST NAME:
* FIRST NAME:
* INTAKE DATE:
/ /
* DATE OF BIRTH:
/ /
* GENDER:
Middle Name:
MONTH
MONTH
YEAR
DAY
YEAR
11 Male
ADDRESS
LIVING SITUATION * HOUSING:
Street:
City:
DAY
* STATE:
* ZIP CODE:
01 Homeless On Street 02 Homeless In Shelter
07 Skilled Nursing Facility Or Hospice
03 Transitional Housing
08 Hospital
04 Residential Psychiatric Facility
09 Correctional Facility (Jail / Prison)
05 Residential - Group Home 05 Residential-Drug Treatment
10 Permanent Housing Rental 11 Permanent Housing Owns Home 12 With Relations / Friends 13 Domestic Violence Situations
Chronic Homelessness (as defined by HUD)
* COUNTY: Select
One * PRIMARY LANGUAGE SPOKEN: Telephone:
( ) - ( ) - Day
Evening
Can Client Be Contacted?
✘ Discretion
Home Visit
(Please Check All That Apply)
By Mail
✘ Phone
Language Selection Language Selection
Language Selection
Language Selection
* REFERRED BY ~ SOURCE:
101 Physician 102 Community Health Center 103 Designated AIDS Center Hospital 104 Other Hospital 105 TB Clinic 106 STD Clinic 107 Family Planning / PCAP 108 Home Health Agency 109 Emergency Medical Services 111 ICF (Intermediate Care Facility) 112 Residential Health Care Facility 113 Skilled Nursing Facility 114 HIV Counseling & Testing
501 Community Service Provider (CSP) 502 Community Based Organization (CBO) 503 Adolescent Service Program 504 Shelter / Hotel 505 Supportive Housing Provider 506 Local Department of Social Services 507 Foster Care Agency 508 CFP / COBRA Case Management Agency 509 Women’s Service Organization 520 Migrant Education Program
651 HIV + Partner 652 HIV - Partner 653 HIV Status Unknown Partner 654 Friend Or Family 655 Media 656 Hotline ✘ 657 Street Outreach / Education 658 Self 659 Hemophilia Association 701 Drug Rehab Program 702 Detox Program 703 Substance Use Program 704 Alcohol Use Program
999 Other:
(Please Check Appropriate Box)
*
* PERSON COMPLETING INTAKE:
IN HOUSE
✘ EXTERNAL
Xavior R. Ford
* CLIENT ASSIGNED TO SITE: Harlem
* PROGRAM PERFORMING INTAKE:
United
WBA
Organization:
801 Community Mental Health Program 802 Psychiatric Services Provider 803 Psychological Counseling Provider 901 Legal Services Provider 902 Correctional Association Hotline 903 Division of Parole 904 Rape Unit 905 Department of Corrections 906 Criminal Justice Initiative 907 Other Inmate
* ETHNICITY:
NON-HISPANIC
* INSURANCE:
HISPANIC
(Please Check Only One Response)
KNOWN, SPECIFY Detail:
Select One
Select One
Select One
✘ UNKNOWN / UNREPORTED
Detail: Select One
* RACE:
(Enter In Insurance History)
NO INSURANCE
WHITE
BLACK OR AFRICAN AMERICAN
HOUSEHOLD DATA:
Select One
CLIENT REFUSED TO ANSWER
AMERICAN INDIAN OR ALASKA NATIVE NATIVE HAWAIIAN / PACIFIC ISLANDER Asian
Household Size:
Select One
SOME OTHER RACE
Total Household Income (annual): $
Special Circle All that Apply In This Category): 01 Recent Immigrant 02 Prison Release / Probationer 03 Migrant / Seasonal Farm Worker 04 Mentally Ill Chemical Abuser 05 Women 06 Adolescents ✘ 07 Gay Man Of Color 08 Other 09 Veteran 10 Inmate Of DFY Facility 11 Family Of Inmate Of DFY Facility 12 Transgenders 13 Sex Workers
17 Injection Drug Users (IDUs) 18 Unprotected Heterosexual Contacts ✘ 19 Same Sex Contacts 20 Sex Contacts / IDU 21 General / Community Volunteers 22 Pediatrics 23 Seriously & Persistently Mentally Ill 24 Tuberculosis Infected 25 Mentally Retarded / Developmentally Disabled 26 Physically Disabled 27 Active Or Recovering Alcohol Or Drug Use 28 Mother Or Pregnant Woman With / At Risk For HIV
29 Alcohol Abuser 14 Homeless ✘ 15 Minority Population
16 Substance Users
Comments:
30 Drug Abuser 31 Domestic Violence Victim