Confidential

Intake Form

This confidential intake form collects demographic and service request data to help us coordinate care and meet King County grant reporting requirements. All questions are optional unless noted.

Consent

I understand services are voluntary and confidential. I consent to my information being used for program coordination and reported in aggregate (de-identified) for King County grant requirements.

Date

First Name (optional)

Last Initial (optional)

Household Size (optional)

Income Range (optional)

Veteran (optional)

Yes

No

Prefer not to say

Disability (optional)

Yes

No

Prefer not to say

Zip Code

City/Neighborhood (optional)

County (optional)

King

Other

Prefer not to say

Signature

Prayer Needs (optional)