Neftaly Client Intake Form Template
Client Intake Form
This form is designed to collect essential information from clients seeking services through Neftaly. All information provided will be kept confidential and handled in accordance with applicable privacy regulations.
Client Information
Full Name:
Date of Birth:
Gender:
☐ Male ☐ Female ☐ Non-Binary ☐ Prefer Not to Answer ☐ Other: ___________
Contact Information:
- Phone Number:
- Email Address:
- Preferred Method of Contact:
☐ Phone ☐ Email ☐ Text ☐ Other: ___________
Home Address:
Emergency Contact:
- Name: ______________________________________
- Phone Number: __________________________________
- Relationship to Client: __________________________
Demographic Information (Optional, for reporting and program evaluation purposes)
Ethnicity/Race (Check all that apply):
☐ Caucasian
☐ Hispanic/Latino
☐ African American
☐ Native American
☐ Asian/Pacific Islander
☐ Other: ___________
☐ Prefer Not to Answer
Primary Language Spoken:
Educational Level:
☐ High School or Less
☐ Some College
☐ College Graduate
☐ Postgraduate
☐ Other: _______________
Service Needs and Preferences
Please describe the reason for seeking services:
What specific services are you interested in? (Check all that apply)
☐ Social Services
☐ Mental Health Support
☐ Housing Assistance
☐ Financial Assistance
☐ Employment Support
☐ Legal Assistance
☐ Other: _______________
Do you have any immediate needs or concerns that need to be addressed first?
☐ Yes ☐ No
If yes, please describe:
Preferred Service Delivery Method:
☐ In-Person
☐ Virtual (Phone/Video)
☐ Hybrid (Both In-Person and Virtual)
Health and Accessibility Information (Optional, to provide appropriate accommodations)
Do you have any medical conditions or disabilities that we should be aware of to provide better assistance?
☐ Yes ☐ No
If yes, please describe:
Do you require any special accommodations for accessibility (e.g., wheelchair access, interpreter)?
☐ Yes ☐ No
If yes, please specify:
Insurance Information (If applicable)
Do you have health insurance?
☐ Yes ☐ No
If yes, please provide the following information:
- Insurance Provider: ______________________________________
- Policy Number: ______________________________________
- Group Number (if applicable): __________________________________
Referrals and Consent
How did you hear about Neftaly services? (Check all that apply)
☐ Referral from a friend/family
☐ Referral from a healthcare provider
☐ Social Media
☐ Website
☐ Event/Community Outreach
☐ Other: _______________
Are you willing to participate in a follow-up survey or provide feedback about our services?
☐ Yes ☐ No
Client Consent and Acknowledgements
By signing below, I acknowledge that the information provided in this form is accurate to the best of my knowledge. I consent to the use of this information for the purposes of receiving services from Neftaly, and I understand that my information will be kept confidential in accordance with privacy laws.
Client Signature: ________________________________
Date: __________________________________________
Staff Member Name (if applicable): ______________________________
Staff Member Signature (if applicable): ___________________________
Date: __________________________________________
This Client Intake Form ensures a standardized and comprehensive approach to gathering client data, while maintaining privacy and confidentiality in compliance with relevant regulations (e.g., HIPAA, GDPR). It can be customized based on specific service needs and privacy guidelines for Neftaly.