Elizabeth Kiwaha and

John Kiwaha, Founders

info@Ohanahomefoundation.org

www.Ohanahomefoundation.org

 

Client Intake Information      

 

Today’s Date: Date

Full Name (First, Middle, Last):Client first nameClient middle nameClient last name

 
Date of Birth: Client birthdate Age: Text field

SSN: SSN

Gender:  Client gender

Phone: Client phone

Email: Client email

 

Current Physical Address: (or where you are arriving from)

Client Address

Client City

Client StateClient Zip

Veteran? Client veteran status

If yes, how many years served? Text field

Branch: Dropdown

 

Which forms of ID do you currently have: 

 Dropdown

 

 

Income

Checkboxes

 

 

Food Stamps:

Checkboxes

 

 

Healthcare

Checkboxes

Private Insurance Carrier (if applicable): Text field

 

 

Do you currently have a primary doctor? Checkboxes

If yes, provide doctor’s name and contact number:

Doctor's Name: Text field

Doctor's Phone Number: Text field

 

If no, when was the last time you were seen by a doctor? Text field

 

Do you currently have a dentist? Checkboxes

If yes, provide dentist’s name and contact number?

Dentist's Name: Text field

Dentist's Phone Number: Text field

 

If not, when was the last time you were seen by a dentist?Text field

 

Any mental health services or medication in the past or present?  Please list. (include MAT) Paragraph

 

Any Chemical dependency past or present? List all drugs used or abused: Paragraph

What is your Drug(s) of Choice? Paragraph

 

What was the last day you used drugs and/or alcohol? Date

 

If you receive MAT, where are you going for treatment: Text field

 

Have you completed IOP? Please list any other programs you’ve completed: Paragraph

Do you have a sponsor? If yes, please provide their name and number. Client sponsor

Sponsor's Name:Text field

 

Sponsor's Phone Number: Text field

 

Housing history

Times you lost housing and why: Paragraph
 

Any debts or Legal Financial Obligations (LFOs): Checkboxes

 

Incarceration or Arrest history

Do you have a felony record? Checkboxes

If yes, list all convictions in the last 5 years.

Paragraph

Any charges pending: Checkboxes

Charge Text field

County Text field

Status Text field

 

Charge Text field

County Text field

StatusText field

 

Are you currently on Probation or Parole? Checkboxes

 

If yes, who is your current probation or parole officer?

Name: Text field

Phone: Text field

 

Are you working with drug court? Checkboxes

 

List any existing or pending court dates and where:

Text field

NOTE: We do not provide transportation to and from court appearances.

 

Are you working with any other organization or case managers? Are they helping with financial and other resources? If yes, please provide the agency’s name.

Text field

 

Work history

Are you working or looking for work? Checkboxes

Current Employer (if applicable): Text field

 

What are your current work skills, or what types of jobs have you had in the past? Paragraph

 

Do you plan on attending school or training? Checkboxes

If yes, what type of education or training? Text field

 
 

Please describe your current, short-term, and long-term goals.  Paragraph

 

Emergency Contacts/Family or friends (List in the order you would like us to contact them)

    Contact

 

What motivates you to pursue sobriety? What deeper purpose drives your decision? If you'd like, sharing your reason(s), your “why” can be a helpful reminder during challenging times.

 Paragraph

 

  
 

Applicant Signature Signature DateDate

Applicant Printed Name: Client first name Client last name

                                                                                                                                 

OHF Representative Signature SignatureDate Date

OHF Representative Printed Name: Text field