HANDS HELPING FRIENDS · LA
Los Angeles, California  EIN 33-3322430  ·  CCN 6575197
helpinglosangeles.org


Client Intake Form
Please print clearly. All information is kept strictly confidential.
Intake Form ID #: ______________________________     Program Site Assignment: ________________________________________
PERSONAL INFORMATION
Full Name: _________________________________________________________________________________________________________
Street Address: ____________________________________________________________________________________________________
City: ________________________________________     State: ________     Zip: ____________
Last Four of SSN: __________     Birth Date (MM/DD/YYYY): ____________________
Gender:  ☐ Male   ☐ Female   ☐ Other   
Marital Status:  ☐ Single   ☐ Married   ☐ Divorced   ☐ Separated   
Driver's License / ID #: ________________________________________     Issuing State: _______________
Cell Phone: _________________________     Alternate Phone: _________________________
EMERGENCY CONTACTS
Name: ________________________________________     Relationship: ____________________     Telephone: ____________________
Name: ________________________________________     Relationship: ____________________     Telephone: ____________________
BACKGROUND
Veteran:  ☐ Yes   ☐ No     Branch: _____________________________________________
Probation / Parole: ______________________________     Location: ________________________________________
Parole/Probation Officer's Name: ________________________________________     PO Phone #: ____________________
MEDICAL
Current medications:
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Are you under a physician's care?  ☐ Yes   ☐ No     If yes, why: ________________________________________
:
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Doctor's Name: _________________________     Phone: __________________     Agency: ____________________
List all physical medical problems:
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BEHAVIORAL HEALTH
List all past and current psychiatric encounters:
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Under care of a behavioral health facility?  ☐ Yes   ☐ No     Agency / How long: ______________________________
:
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Prescribed psychotropic meds?  ☐ Yes   ☐ No   
Do you possess these meds?  ☐ Yes   ☐ No   
Medications prescribed:
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Will your doctor prepare a work release letter?  ☐ Yes   ☐ No   
Have you ever attempted suicide?  ☐ Yes   ☐ No     If yes, explain: ________________________________________
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Caseworker / Doctor Name: _________________________     Phone: __________________     Diagnosis: _________________________
SUBSTANCE USE
Drug(s) of choice:
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Date of last use: __________________________________________________________________________________________
Can you pass a drug test today?  ☐ Yes   ☐ No   
BENEFITS & INCOME
Currently receiving county, state, or federal benefits?  ☐ Yes   ☐ No     What: ______________________________
Why:
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Ever received county, state, or federal benefits?  ☐ Yes   ☐ No     What: ______________________________
Why:
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LIVING & EMPLOYMENT
Current Living Situation:  ☐ Streets   ☐ Shelter   ☐ Detox   ☐ Jail   ☐ Rental   ☐ Hospital   ☐ DV Shelter   ☐ Motel   
Currently Employed?  ☐ Yes   ☐ No     If no, last place of employment: ___________________________________
Date Last Worked: __________________________________________________________________________________________
Name, address & phone of current employer:
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Pay Rate: _______________     Type of Employment: _________________________     Current Income: ____________________
VERIFICATION CONTACT
Who can we call to verify application?  ☐ PO   ☐ Public Defender   ☐ Attorney   ☐ Case Manager   ☐ COIII   ☐ Pretrial   ☐ Other   
Contact Name: ___________________________________     Phone # (required): _________________________
Fax (required): __________________________________________________________________________________________
If incarcerated, a contact name is required to process the application.
LEGAL STATUS
Do you have current charges?  ☐ Yes   ☐ No     If yes, what: ________________________________________
Next Court Date: __________________________________________________________________________________________
Are you a parole violator?  ☐ Yes   ☐ No     Reason for violation: ___________________________________
Anticipated Release Date: ________________________________________________________________________________
Supervision:  ☐ IPS   ☐ Direct   ☐ Regular Parole   ☐ Fed Probation   ☐ None   
Supervising Agency: __________________________________________________________________________________________
PO Name, Phone, Office Location:
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Court Fines?  ☐ Yes   ☐ No     How much ($): _________________________
Community Service?  ☐ Yes   ☐ No     How many hours: _________________________
Where are you assigned?:
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PROGRAM ENTRY
Referred By: ________________________________________     Entry Date: ____________________
Lived at Hands Helping Friends LA before?  ☐ Yes   ☐ No   
When / Where: __________________________________________________________________________________________
Conditions of Entry:
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ACKNOWLEDGEMENT
I certify that the information provided is true and complete to the best of my knowledge. I understand that any false statements may result in denial or termination from the program.
Print Name: _____________________________________________     Date: ____________________
Applicant Signature: _______________________________________________________________________________________________
Intake Processed By: ________________________________________     Date: ____________________