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HUES Women's Health Advocacy Institute Intake Form

(To Be Completed with Client)

Date completing the form:

Script: Hello, my name is [Your Name], and I'm a health advocate with HUES Women's Health Advocacy Institute. I am calling to follow up on your call. Are you requesting services? If so, I will work with you to complete an intake questionnaire, which helps us understand your needs so we can connect you with the best resources available.

Script: First, let's get some basic information. This is all kept confidential.

Full Name

Date of Birth (Date)
Cell or Home Number
Email Address

Street Address

Script: Next, we'll talk about what you need assistance with. Now, a very important question: Can you please describe your current health needs? This includes any disabilities, chronic illnesses, and any medications you are taking. This information helps us understand your needs fully and connect you to health-related resources if needed.

Okay, thank you. Now, looking at this list, which types of assistance are you requesting? You can select more than one.

(Read aloud the list and mark the client's selections: Food, Personal Care, Transportation, Clothing, Housing, Employment Assistance, Financial Assistance, Mental Health, Physician.)

Current Health Needs:

Type of Assistance Requested:

Type of Assistance Requested:

Script: Finally, can you describe your reason for requesting this assistance? This helps us understand your situation better.

Reason for request:

Script: This is the most critical part. You must read the consent statement exactly as it appears on the form. Thank you. Before we finish, I need to read this consent statement to you. It's very important that you understand it. Please listen carefully:

I, hereby, consent to the release of any information required by the organization or agency providing the services to determine my eligibility for services. This information may include personal and financial information, employment history, medical records, and any other information necessary to determine my eligibility for services.

I understand that this information will be used solely for the purpose of determining my eligibility for services and will be kept confidential in accordance with applicable laws and regulations. I understand that I have the right to request a copy of this consent form and to revoke this consent at any time. By allowing the representative of HUES to sign below, I acknowledge that it understand the terms of this consent form and that I have given the representative permission to sign on my behalf.+

Script: Do you understand and agree to the terms of this consent?

Great. Can you please confirm your full name for the client signature?

Okay, I will now sign my name as the HUES representative.

And the time is [Current Time].

First and Last Name of Client:

HUES Representative First and Last Name

Time of form completion

Script: Thank you for taking the time to complete this with me. We will be in touch within 72 hours regarding the next steps.

Resource Provision Form (To be completed immediately after intake)

Resource Type Provided (Select All That Apply):

Organization Referring To:

Organization Contact Information:

Details about the referral process, next steps, etc.:

Channel of Contact

Channel of Contact

Use additional lines below if referring to more than one company:

Organization Referring To:

Organization Contact Information:

Details about the referral process, next steps, etc.:

Channel of Contact

Channel of Contact

Organization Referring To:

Organization Contact Information:

Details about the referral process, next steps, etc.:

Channel of Contact

Channel of Contact