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HIPAtlanta

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PARTICIPANT INTAKE FORM

GENERAL INFORMATION

Participant's address and phone number




Name, Address and phone # of 2 contacts (people who will always know how to reach the participant):









Please provide the contact information of participant's probation or parole officer (if applicable):
  1. How long has the participant been living at the present address?
    (Check only one)

    Not Applicable
    Currently Homeless
    Up to 3 Months
    Between 4 and 6 months
    Between 7 and 12 months
    Between 1 Year and 3 Years
    Between 3 Years and 5 Years
    More than 5 Years
  2. Date of enrollment:
  3. Did you reach out to this participant prior to his / her enrolling into the program through any of the following means? (Check all that apply)
    Community Presentation
    Other Direct Outreach (describe)
    Community Outreach
    No, participant not contacted through outreach activities
PERSONAL INFORMATION
  1. Participant's date of birth: (month/day/year) (required)
  2. Participant's place of birth: U.S.A. What state?
    Other (Specify)
  3. Last 4 digits of Participant's Social Security:
  4. Participant's Prison Identification or Inmate Number:(if applicable)
  5. What is the participant's gender? Male Female
  6. What is the participant's first language? (Check one)
    English
    Spanish
    Other (Specify)
  7. What is the participant's current martial status? (Check only one)
    Single
    Separated
    Married
    Divorced
    Common Law (legally married without a license or ceremony)
    Widowed
  8. Does the participant have any children?
    How many?
  9. Does the participant have to pay child support?
    Yes
    No
  10. Please describe the residents in participant's household at time of intake: (Check all that apply)







EDUCATIONAL / EMPLOYMENT INFORMATION
  1. What is the participant's current employment status? (Check only one)



  2. If working, how many hours per month did the participant work and how much did the participant earn last month?
    Hours Worked:
    Wages Earned: $ (per month after taxes)
  3. What is the participant's occupation?
  4. What is the highest grade or year of school the participant completed? (Check only one)










  5. Is the participant currently involved in school or educational programming?








By signing, I attest that the information above is complete and true to the best of my knowledge. I also give permission to (YOUR AGENCY NAME) to verify placement with my future employer.

NAME OF PARTICIPANT:
Date:
        
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