New Chapter Life Solutions Inc.

1 Participant Information

Basic identification details.

Intake Date:

First Name *

Last Name *

Also Known As / Nickname

Date of Birth *

Age

Gender Identity *

Female Male Non-Binary Prefer Not to Say

Race / Ethnicity

Social Security Number

Medicaid Number

Do you currently have health insurance? *

Yes No

Insurance Provider

Policy #

2 Contact Information

How we can reach you.

Phone Number *

Email Address

Current Address *

City *

State

Zip

County of Residence

3 Emergency Contact

Someone we can contact in an emergency.

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

4 Justice Involvement History

Your recent justice involvement details.

Release Date

Releasing Facility

Current Legal Status

Probation Parole Post-Release Supervision No Current Supervision

Supervising Officer Name

Officer Contact

5 Health Information

Help us understand your health needs.

Have you ever received mental health services?

Yes No

Current Medications

6 Housing

Your current living situation.

Housing Type

Housing Needs or Concerns

7 Employment & Education

Your work and education background.

Current Employment Status *

Employed Full-Time Employed Part-Time Unemployed Unable to Work

Employer Name

Highest Level of Education

Employment Barriers

8 Family & Social Support

Your family and support network.

Marital Status

Do you have children?

Yes No

Number of Children

Primary Support System (check all that apply)

9 Program Needs & Goals

Tell us how we can best support you.

Primary Needs (check all that apply) *

Short-Term Goals *

Long-Term Goals

Referral Source

Are you a Work First referral?

Yes No

10 Consent & Signature

Please read and agree to the following.

Participant Signature (Type full name) *

Today's Date

Consent to Services

Emergency Contact Authorization

HIPAA Notice of Privacy Practices

Release of Information

Grievance Policy

Certification of Accuracy

Intake Form Submitted!