CONSUMER INTAKE RECORD
Consumer Information:
Name:_______________________________________ Date of Intake: __/__ /__
Address:_____________________________________ Date of Birth: __/__ /__
City:_______________________ State_________ Zip________ Age _____
Phone: (_____) _______-_______ Male___________ Female____________
TDD: (_____) _______-_______ U.S. Citizen ________ Veteran_________
County:_____________________ Social Security Number _____ ____ _____
Living Arrangements:
Assisted Living _______ Dependent w/family/friends _______ Independent _______ Institution_________ Other_________
Demographic Information:
Disability: Primary ________________________ Secondary___________________
Multiple: Yes No (circle one) Years Disabled:_______________
Martial Status: _____________________________ Referral Source: ______________
Employment Status: _________________________ Income Source: ______________
Voc. Rehab. Client? Yes No (circle one) Education: __________________
Race_________________________
Other Information:
Transportation: Drive _____ Own Vehicle ____ Private arrangement ____ Public____
No accessible transportation______
Desired Classes: 1.___________________________ 2. ________________________
Registered Voter: Yes No (circle one)
The information given here is true and correct to the best of my knowledge.
_____________________________/_______________/ _______________________
Consumer Signature Date Staff Signature