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MI is ME
Intake Form
Advocate partner & organization's name
Name
*
Email
*
Last address lived at
*
When, and for how long?
*
Occupation
*
Income source
*
Past work history & date
*
Salary
*
Date of birth
*
Medical coverage
*
Yes
No
Provider
*
Food stamps
*
Yes
No
Food stamp amount
*
Date rec'd.
*
Education level completed
*
Computer experience
*
Yes
No
Trade(s)
*
Certifications/licenses
*
List software knowledge
*
Driver license number & state
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I.D. number & state
*
Birth certificate state
*
Probation
*
Yes
No
Parole
*
Yes
No
Terms
*
List continuing education
*
Goals
*
Children
*
Yes
No
Ages and gender
*
Spouse's name
*
Schools attended
*
Highest grade completed
*
Current address
*
Contact phone number
*
Reason for current living circumstance
*
Are interested in having a flu vaccine or any others?
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Do you currently have any medication concerns?
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Do you currently have any physical ailments?
*
Is there currently a medical, legal, emotional, or other situation that you need immediate assistance with?
*
Religion?
*
Request prayer visits?
*
Yes
No
Request woman wellness?
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Yes
No
Domestic violence circumstance?
*
Yes
No
Depression
*
Yes
No
Suicide
*
Yes
No
Smoker?
*
Yes
No
What kinds of activities do you like doing?
*
Do you have any hobbies?
*
Registered to vote where?
*
Party?
*
How often are you able to be active?
*
Church attended?
*
Active in sports?
*
Yes
No
Type of sport (if applicable)
Support group attended?
*
Enrolled in therapy?
*
Yes
No
Type of therapy (if applicable)
Are you social?
*
Yes
No
How? Why not? (if applicable)
Emergency Point of Contact Information:
Name & Relationship
*
Address
*
Health care team of professionals
Name/Title/Occupation
*
Name/Title/Occupation
Name/Title/Occupation
Phone
*
Phone
Phone
Diagnosis
*
Is there currently a situation that you need immediate assistance with?
*
How do you handle stress?
*
How often are you lonely or feeling sad?
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What do you do to feel better?
*
Have you ever considered suicide?
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Yes
No
When? (if applicable)
Why?
*
How can I help?
*
Anybody you know ever felt suicidal?
*
Yes
No
Who? (If applicable)
What is the most important thing to you?
*
Last 4 social security numbers
*
Printed name
*
Date
*
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Access Help Line Referral Info?
1 (844) 36HELP2
I consent to the following personal information being collected on my behalf by MI Mother's Keeper & its affiliates for the sole purpose of helping me to find mental wellness, employment, social service, medical, and other resources in order that I can change my current life circumstance for the better. I release and hold harmless MI Mother's Keeper & its affiliates from any future claims that may arise as a result of their intent to advocate on my behalf.
*
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