SNCIL Consumer Intake Form

Date

Entered CIL First Date

Initial(required)

Staff

Your First Name (required)

Your Last Name (required)

Home Phone(required)

Cell Phone (required)

Your Email (required)

Address(required)

City (required)

State(required)

Zip (required)

County

Date Of Birth (required)

Age (required)

Sex (required)FemaleMale

Ethnicity:
a) Whiteb) Blackc) Hispanicd) Asiane) American Indian/alaskanf) Other

US Veteran
YesNo

Refereed By:

Refereed Phone:

Beginning Community-Based Living:
a) Institutionb) Dependent w/family & friendsc) Assisted Livingd) Independente) Homelessf) Other

Employment Status at Entry
a) Full Timeb) Part Timec) Retiredd) Shelterede) Lookingf) None

Education:(Optional)
a) Grade School/Lessb) Some Jr./Sr. High Schoolc) High School Graduated) Vocational/Tradee) Some Collegef) College Graduateg) Post Graduate Studyh) Now In Schooli) None of the Above

Education Goal if in School

Transportation:
a) Drives Own Vehicleb) Uses Driverc) Arranges Transportationd) Public Transportatione) No Transportation

Marital Status:
a) Singleb) Marriedc) Divorcedd) Widowedc) Separatedd) Othere) #Minor Children

Source of Income:
SSDIVAOther TypeSSIPrivateInc. LevelFood StampsOtherTotal

Health Benefits:
a) Medicareb) Medicaidc) Privated) Other