Male Transgender: M to F Doesn’t identify as male, Gender   Transgender: F to M female or transgender Female Ethnicity   Non-Hispanic/Latino Hispanic/Latino American Indian or Native Hawaiian or Black/African American Alaskan Native Pacific Islander Primary Race   Asian American Indian or American Native Hawaiian or Other Secondary Alaskan Native Pacific Islander Race (Leave NA NA Blank if None) White Asian Primary English Spanish Other, specify: Language   Yes No (If Yes) how long ago was the last incident? Domestic Within the past 3 months 3-6 months ago 6-12 months ago    Violence More than a year ago Client Know Client Refused    Victim/Survivor (If Yes) are you currently fleeing? Yes No Client Does Not Know Client Refused     Disabling   Yes No Conditions: Continue to Disability Assessment Client Name: Disability Assessment Documentation Currently receiving Will the of disability Services or Condition be Disability and severity Disability Type (If Yes) Date Treatment? long term? Determination on file Yes Yes Yes Doesn’t Know Doesn’t Know Yes Alcohol Abuse _____/_____/_____ No No No Refused Refused No Yes No If Yes, Expected to be of long-continued and indefinite duration Yes No Client Doesn’t Know Client Refused Client doesn’t know and substantially impairs ability to live independently? Client Refused Notes: Yes Yes Yes Know Doesn’t Know Yes Drug Abuse _____/_____/_____ No No No Refused Refused No Yes No If Yes, Expected to be of long-continued and indefinite duration Yes No Client Doesn’t Know Client Refused Client doesn’t know and substantially impairs ability to live independently? Client Refused Notes: Alcohol and Yes Yes Yes Doesn’t Know Doesn’t Know Yes Drug Abuse _____/_____/_____ No No No Refused Refused No If Yes, Expected to be of long-continued and indefinite duration Yes No Yes No Client Know Client Refused and substantially impairs ability to live independently? Client doesn’t know Client Refused Notes: Chronic Health Yes Doesn’t Know Yes Yes Doesn’t Know Yes Condition _____/_____/_____ No No No Refused Refused No If Yes, Expected to be of long-continued and indefinite duration Yes No Yes No Client Doesn’t Know Client Refused and substantially impairs ability to live independently? Client doesn’t know Client Refused Notes:
Gender Male Female Transgender: M to F Transgender: F to M Doesn’t identify as male, female or transgender   Ethnicity Non-Hispanic/Latino Hispanic/Latino   Primary Race American Indian or Alaskan Native Asian Black/African American Native Hawaiian or Pacific Islander   Secondary Race (Leave Blank if None) American Indian or Alaskan Native Asian American White Native Hawaiian or Other Pacific Islander NA NA Primary Language English Spanish Other, specify: Domestic Violence Victim/Survivor Yes No   (If Yes) how long ago was the last incident?  Within the past 3 months  3-6 months ago  6-12 months ago  More than a year ago  Client Know  Client Refused (If Yes) are you currently fleeing?  Yes  No  Client Does Not Know  Client Refused Disabling Conditions: Yes No   Continue to Disability Assessment Client Name: Disability Assessment Disability Type (If Yes) Date Currently receiving Services or Treatment? Will the Condition be long term? Disability Determination Documentation of disability and severity on file Alcohol Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Doesn’t Know Refused Yes No Yes No Doesn’t Know Refused Yes No If Yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes No Client Doesn’t Know Client Refused Notes: Drug Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Know Refused Yes No Yes No Doesn’t Know Refused Yes No If Yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes No Client Doesn’t Know Client Refused Notes: Alcohol and Drug Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Doesn’t Know Refused Yes No Yes No Doesn’t Know Refused Yes No If Yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes No Client Know Client Refused Notes: Chronic Health Condition Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Doesn’t Know Refused Yes No Yes No Doesn’t Know Refused Yes No If Yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes No Client Doesn’t Know Client Refused Notes:
Universal_Intake_Form_20170622.docx