PIONEER Center for Human Services

TAB: Intake

INTAKE APPLICATION

Be sure to complete each blank/question-unless not applicable; then put N/A. (All information is confidential)

Name: Date:

Address: Home Phone: Alternate Phone: County: How long at this address?

Township: Mother’s Maiden Name: ______

Marital Status: Single Married Widowed Separated Divorced

SSN: Birthdate: Age: ______Gender: Male Female _____ Birthplace: ______

Referred by______

State the areas of need that Pioneer Center can assist you with: ______

If client is 17 or older, has client been convicted of a felony? If client is 18 or older, has client been convicted of a misdemeanor?

Yes No If yes, what year? ______

What ______

______

When ______

Has client previously completed an application with this organization?

Diagnosis: ______

If Developmentally Disabled, date of onset: ______

Are you a veteran? Yes No

Do you have a court appointed legal guardian? Yes No _____

If yes, name of guardian: ______

**Please provide a copy of the guardianship papers**

PRIMARY LANGUAGE: English ______Spanish ______Other ______

MODE OF COMMUNICATION: Speaks_____ Writes _____ Signs _____

Assistive Devices _____ Other ______

EDUCATION:

Highest Grade Completed: ______Year: ______School: ______

Degree: ______

Vocational Training Experience, Certificates, Apprenticeships, Licenses:

______

______

EMPLOYMENT EXPERIENCE: (For client only, if applicable, begin with most recent job)

Employer Name / Job Title / Employment Dates / Reason for leaving

If currently unemployed, how long? ______

NATURAL SUPPORT SYSTEM:

(Residing with you - including Spouse, Children, Parents, Siblings, Relatives, Friends)

NAME / SEX / AGE / BIRTHDATE / MARITAL STATUS / RELATIONSHIP TO SELF / ADDRESS / PHONE #

MEDICAL/HEALTH INFORMATION:

Physician: Phone Number: ______Address: ______Psychiatrist/Psychologist: Phone Number: Address: ______Therapist: Phone Number:______Address: ______


DO YOU HAVE THE FOLLOWING:

PUBLIC AID BENEFITS?

Food Stamps

Medicaid

Medicaid Spenddown

Medicaid QMB

Assistance to Aged Blind Disabled (AABD) $ ______

______Health Benefits for Workers with Disabilities

q  SOCIAL SECURITY BENEFITS ?

Supplemental Security Income (SSI) $

Social Security Disabled Adult Child (SSDAC) $

Social Security Disability Insurance (SSDI) $

q  MEDICARE BENEFITS?

q  VETERAN BENEFITS?

q  PENSION BENEFITS?

q  OTHER FINANCIAL SOURCES?

Type:

CILA Services?

q  Home based services?

Total gross family income is $ #of Dependents

Are you currently being claimed as a dependent by your family or someone else? Yes No

Signature of Applicant Date

Signature of Guardian (Parent if child) or if applicant has a Date

court appointed guardian

Revised 3/00, Updated 11/01, Updated 8/03 klb, 09/06 tfd, 05/08cb

1