HSA - Intake Questionnaire

Client's Name: First: MI: Last:

Gender: Male Female Maiden Name:

Address: City: State: ZIP:

Phone: (Home) (Work) (Cell)

Email:

Date of Birth: Social Security #: County of Residence:

First two letters OF YOUR MOTHER'S FIRST NAME: (used in creation of a unique ID number):

Emergency Contact: Relationship to you:

Phone: (Home) (Work) (Cell)

Person responsible for payment: Social Security #:

Address:

Phone:(Home) (Work) (Cell)

Do you have:

Insurance Yes No (If yes, please bring your insurance card with you and contact your insurance company regarding coverage and if pre-authorization is required).

Medicare Yes No (If yes, please bring your card).

Medicaid Yes No (If yes, please bring your Medicaid card; if you are Medicaid Managed Care, please see that either you or your doctor supply us with the referral card prior to your appointment).

Hispanic Ethnicity: (please check one)

Cuban

Not of Hispanic Origin

Hispanic-SPECIFIC ORIGIN NOT SPECIFIED

Other specific Hispanic

Mexican

Puerto Rican

Race: (please check one)

Alaska Native

Native Hawaiian/Pacific Islander

American Indian

White

Asian

Other

Black or African American

Adult Living Arrangements: (18 and over - please check one)

Adult Foster Care

Transitional Facility

Alone/Independent Living

With Children

Group Home

With other Family member

Homeless

With Parent

Nursing Home

With Spouse and Children

Other

With Spouse

Other Public/Private

Unrelated Person

Supportive Living

Adolescent Living Arrangements: (Under 18 - please check one)

Both Parents

Parent/Step-Parent

Foster Home

Private Care Facility

Homeless

Public Care Facility

Independent Living

Single Parents

Other

Therapeutic Foster Home

Other Relative

**Answer only if HOMELESS was checked on Living Arrangements

4 or more Homeless episodes in past 3 years

Continually Homeless for a year or more

Homeless but 1 or 2 not applicable

Do you understand English? (Please check one)

Full

Limited

Requires Assistance

What is your preferred language: (if other, please list)

English

Spanish

Other

Do you work?

Full-time

Not in the labor force

Part-time

Unemployed

What is your occupation: (Only needed if not in Labor Force was checked)

Disabled

Other

Homemaker

Retired

Inmate of Institution

Student

Not Applicable

Employment Length: (please check one)

Less than 6 months

5-7 years

6 months but less than 1 year

8-15 years

1 year

16-20 years

2-4 years

21 or more years

Marital Status

Now Married

Never Married

Divorced

Seperated

Widow

Are you a Veteran? (please check one)

Yes

No

What is the highest grade you completed in school? (enter a number)

Are you in Special Education?

Yes

No

Who referred you to the Human Service Agency? (please check one)

Alcoholic Anonymous/Alateen

Gambling Anonymous

Alcohol/Drug Provider

Human Service Center

Bureau of Indian Affairs

Indian Health Services

Child/Day Care Provider

Information/Referral Hotline

Clergy

Medical Physician

College/University

Narcotic Anonymous

Community Hospital

Nursing Home

Community Mental Health Center

Other

County Board of Mental Illness

Other Healthcare Provider

Court/Criminal Justice Referral

Other Social Services

Department of Social Services

Private Mental Health Professional

Department of Disability Agency

Public Health Nurse/Dept of Health

Division of Alcohol/Drug Abuse

Public Health Services

Employee/EAP

School (Primary/Secondary)

Family/Self-Referral/Friend

Veterans Administration

Financial Counseling

Vocational Rehabilitation

Criminal Justice Referral (Only needs to be filled out if Court/Criminal Justice Referral was checked above)

Attorney

Other Court (Not State or Federal)

Department of Corrections

Other Recognized Legal Entity

Diversionary Program

Prison

DUI/DWI

Federal Probation

State's Attorney

Law Enforcement

State/Federal Court

Not Applicable

Unknown

Other

What is your smoking status/history? (required if over 13 years old)

Current every day smoker

Never a smoker

Current some day smoker

Smoker, current status unknown

Former smoker

Unknown if ever smoked

How did you hear about our facility: (please check one)

Client of HSA

Newspaper

Friends and Family

Yellow Pages

Radio

Other

How would you like to be reminded of your appointment?

Cell text message (Cell #)

Cell Service Provider (AT&T, etc)

Email Address

Phone message (Phone #)

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