XPRES FRM CIF02; Revised 07/29/2014
Page 1 of 3
CLIENT INTAKE FORM
Please check appropriate boxes. If asked a question, fill in information on designated space.
All words that are bold are required information.
Source of Referral:
 Self
 Health Department (County) ________  Friend
 DC
Jurisdiction of referring agency:
 MD  VA
 Other ___________________
 Other:__________
Date of Initial Intake ______________
Personal Information
Revised Date: ___________________
Reviewed Date(s): ________________________________
Sex:
 Male
(check one only)
 Female  Transgender M to F
 Transgender F to M
Client Identification
Ethnicity:
 Hispanic
 Non-Hispanic
Race:
 White
 Black/African American
 Asian
 Native American
Last name _______________________________
First name __________________
MI _______
Date of birth ____________
Age ______
 Native Hawaiian/Pacific Islander
SSN
Medicaid # _______________

More than one race
Address information (provide current address)
Nationality (country of origin) ____________________
Street address: _________________________________
Sexual orientation
City _______________
Zip _________
 Heterosexual
 Bisexual
email _________________
 Homosexual
 Does not apply, child
State ____
Phone _______________
Is this your mailing address?
 Yes
 No
 Unknown/unreported
Marital status
 Single
If no, please provide other address:
Street address: _________________________________
City _______________
State ____
Confidentiality Issues
Can we call ?
Identify as GBMS?
Send mail?
Can we email?
Special instructions:
 Yes
 Yes
 Yes
 Yes
Zip _________
 No
 No
 No
 No
 Married
 Separated
 Divorced
 Co-habitating
 Widowed

 Unknown
Other
Are You a United States Veteran?
 Yes  No
OFFICE USE ONLY: ALL INFORMATION ON PAGE VERIFIED & UPDATED
1ST Review Date:_____________ 2nd Review Date:_________________
GBMS STAFF:____
XPRES FRM CIF02; Revised 07/29/2014
Page 2 of 3
Social Benefits and Entitlements
Your entitlements: (Please check all that apply)
Housing/family/income information
 TANF
 SSDI
 SSI
 Lives alone
 Food stamps
 WIC
 Disability
 W/ spouse or partner
 Unemployment
 Veteran
 GPA/GR
 W/ spouse & children
 Tenant Asst
 ADAP
 HOPWA
 W/ dependent children
 Emergency
 Shelter +Care
 With non-dependent children
 DC Housing
 Child Protective Services
 W/ parents or guardian & dependent children
 Other
 None
Housing status:
 W/ parents or guardian only
Insurance status
 W/ other relatives
Type of medical insurance (Please check all that apply)
 W/ contributing non-relative room mates
 W/ non-contributing, non-relative room mates
 Lives in shelter
 Private

Medicare
 Medicaid

Other public insurance
 VA

None
 Homeless, in street
 Lives in foster care
Name of insurance company _______________________
 Lives in chronic care facility
Agent address __________________________________
Needs Identified:  None 
Plan:
Are you head of household?
 Yes
 No
Client family status
State ____
Zip _______
Phone _________________
email ________________
Co-pay amount ($) _________________
Language/Education Information
 Self
 Mother
 Sibling
 Grandparent  other adult relative
 Other non-related adult
City ___________________
 Father
Client’s spoken language
___________________
Client’s written language
___________________
 caregiver
Caregiver spoken language ___________________
 Child <21, single child home
Caregiver written language ___________________
 Child <21, multi child home
Number of children (<18) in household ________
Total persons in household _______
OFFICE USE ONLY: ALL INFORMATION ON PAGE VERIFIED & UPDATED
1ST Review Date:_____________ 2nd Review Date:_________________
GBMS STAFF:____
XPRES FRM CIF02; Revised 07/29/2014
Page 3 of 3
Contact Information / Social Support
Client’s education:
 None
 Unknown
 Grades 0-6
 Grades 7-9
Please check  if contact has to be done with
Discretion or prior permission in case of emergency or
any eventuality.
Emergency contact:
 Grades 10-12  2 year college
 4 yr college
Contact name ________________________________
 Postgraduate
Address _____________________________________
 Professional  Technical
City ________________ State _____
Zip _______
Employment Information
Phone ___________________
Primary job
 Full time
email ____________
 Part time
Relation to Client: _____________________________
Date of employment ____________________
Company name _______________________________
Special needs/other information
Please check all that apply:
Address _____________________________________
City _______________
State _____
 Hearing impaired
 Visually impaired
 Physically impaired
 Wheelchair bound
Zip ________
Phone ______________ email __________________
 Developmentally disabled
Job title: ____________________________________
 Recently released from incarceration
Second job (if any)
 Full time
 Part time
 Recently incarcerated
Date of employment ____________________
 Chronically mentally ill
Company name _______________________________
 Other need ________________________
Address _____________________________________
 None
City _______________
State ____
Zip _______
Legal Information
Phone ______________ email __________________
Job title: ____________________________________
Income:
Has client ever been convicted of criminal or civil
charges?
Yes
No
Does client have any court cases pending?
Yes
Is client on probation or parole?
Yes
No
No
Assessment
Client needs assistance with legal issues. (e.g.
Annual Individual Income___________________
Health Care Proxy, Will, Living Will, Power of
Attorney, Immigration, Guardianship, Other)
Annual Household Income ___________________
Intervention is needed.
Client needs assistance with legal issues within
the next month.
Client may need legal assistance in the future.
Client has no legal needs at this time.
_____ 100% - 200% of federal poverty level
_____ 200% - 300% of federal poverty level
_____ 300% or > than federal poverty level
STAFF SIGNATURE:____________________
CLIENT SIGNATURE:___________________
DATE(S) REVIEWED:___________________
___________________