Client Intake Form (Sample) Page 2
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1
2List all family members living with you, adults and children: (don’t list yourself here)
1. Full Name: ________________________________________________________
DOB: __________
Age: _______
Gender: Male Female
SS#___________________________
Ethnicity/Race: __________________
Education (Grade Level): _______________
Health Insurance: Yes
No
Disabled: Yes
No
Veteran: Yes
No
2. Full Name: ________________________________________________________
DOB: __________
Age: _______
Gender: Male Female
SS#___________________________
Ethnicity/Race: __________________
Education (Grade Level): _______________
Health Insurance: Yes
No
Disabled: Yes
No
Veteran: Yes
No
3. Full Name: ________________________________________________________
DOB: __________
Age: _______
Gender: Male Female
SS#___________________________
Ethnicity/Race: __________________
Education (Grade Level): _______________
Health Insurance: Yes
No
Disabled: Yes
No
Veteran: Yes
No
4. Full Name: ________________________________________________________
DOB: __________
Age: _______
Gender: Male Female
SS#___________________________
Ethnicity/Race: __________________
Education (Grade Level): _______________
Health Insurance: Yes
No
Disabled: Yes
No
Veteran: Yes
No
5. Full Name: ________________________________________________________
DOB: __________
Age: _______
Gender: Male Female
SS#___________________________
Ethnicity/Race: __________________
Education (Grade Level): _______________
Health Insurance: Yes
No
Disabled: Yes
No
Veteran: Yes
No
6. Full Name: ________________________________________________________
DOB: __________
Age: _______
Gender: Male Female
SS#___________________________
Ethnicity/Race: __________________
Education (Grade Level): _______________
Health Insurance: Yes
No
Disabled: Yes
No
Veteran: Yes
No
7. Full Name: ________________________________________________________
DOB: __________
Age: _______
Gender: Male Female
SS#___________________________
Ethnicity/Race: __________________
Education (Grade Level): _______________
Health Insurance: Yes
No
Disabled: Yes
No
Veteran: Yes
No
8. Full Name: ________________________________________________________
DOB: __________
Age: _______
Gender: Male Female
SS#___________________________
Ethnicity/Race: __________________
Education (Grade Level): _______________
Health Insurance: Yes
No
Disabled: Yes
No
Veteran: Yes
No
9. Full Name: ________________________________________________________
DOB: __________
Age: _______
Gender: Male Female
SS#___________________________
Ethnicity/Race: __________________
Education (Grade Level): _______________
Health Insurance: Yes
No
Disabled: Yes
No
Veteran: Yes
No
CAB, The Shelter Project
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