Toggle navigation
Home
About
Who We Are
What We Do
Success Stories
Sponsors
Programs
News & Events
News
Events
COVID-19 Response
Get Involved
Volunteer
Associate Board
E-News Signup
Careers
Donate
Get Help
Find a Program
3456 W Franklin Blvd, Chicago, IL 60624
773-533-6013
Pre-Intake Application
Intake Worker's Name
Referring Social Worker's Name
Referring Social Worker's Phone Number
Client Information
Client's Name
Client's Date of Birth
Format: 01/01/1990
Client's Last four #'s of SSN
Client's Phone Number
Client's Gender
Choose...
Male
Female
Transgender
Client's Preferred Language
Choose...
English
Spanish
Polish
Other
Please select your preferred language below
Is the client a citizen of the United States?
Yes
No
Income & Shelter
Is this the client's first time homeless?
Yes
No
How long where you homeless?
Do you have Income?
Yes
No
Source of Income
Medical Information
Name of Hospital
Client's Date of hospital admission
Format: 01/01/1990
Through (Estimated date of discharge)
Format: 01/01/1990
Does the Client have a psychiatric history?
Yes
No
What is the client's psychiatric diagnosis?
Axis I
Axis II
Client's Date of Diagnosis
Format: 01/01/1990
Does the client present any of the following?
Cognitive Impairment? (e.g. memory, judgement, etc.)
Yes
No
Thought Disorder?
Yes
No
Dementia?
Yes
No
Paranoia?
Yes
No
Confusion?
Yes
No
If the client has an Acute/Principle illness or injuries, please list them below (one per line.)
Please check any if the following conditions apply to the client.
HIV
Diabetes
Hypertension
Seizure Disorder
Drug or Alcohol Abuse
Is the client taking Methadone?
Yes
No
Why is the client taking Methadone?
What is the client's Methadone dosage?
Insurance Information
What is the Client's Type of insurance?
(Please check all that apply)
None
Medicaid
Aetna
Humana
Illinicare
CountyCare
Meridian
Molina Health
Medicare A/B
Veterans Administration
HMO/Private
Other Insurance:
Assistance Information
Is the client able to manage the following basic living skills
without assistance?
Showering/Hygiene
Yes
No
Dressing Themselves
Yes
No
Manage Bowels/Bladder
Yes
No
Take Medicine As Prescribed
Yes
No
Change Medical Dressings
Yes
No
Manage Medical Supplies
Yes
No
If no to any of the above, How will the client need assistance?
Submit