Client Intake Form

GENERAL INFORMATION

What sector(s) are you interested in?*

Multiple sectors can be selected.

OHL Life
OHL Build
OHL Reform
OHL Educate

Which OHL Life programs & services are you interested in?*

Multiple programs and service may be selected.

Community Forum
Mentoring Program
Counseling
Interactive Discussions
Life Coaching
Media Program
Mediation
Resources

Which OHL Build programs & services are you interested in?*

Multiple programs and service may be selected.

Training
Workshops

Which OHL Educate programs & services are you interested in?*

Multiple programs and service may be selected.

Community Resource Educational Support Team
Continued Education
Language Classes
Naturalization Test Prep

Which OHL Reform programs & services are you interested in?*

Multiple programs and service may be selected.

OHL Reentry InitiativeTake Charge Program

Are you filling out this form for a minor for the first time?*

Yes
No

PARENT/GUARDIAN INFORMATION INFORMATION

Name*

Date of Birth*

Social Security Number*

Address*

Email Address*

Home Phone*

Cell Phone*

Work Phone*

Gender*

Female
Male
Prefer not to say
Other

Other

Please enter your gender.

Ethnicity*

Please select your ethnicity.

African-American/Black
American Indian/Alaska Native
Asian
Bi-Racial
Caucasian/White
Hispanic/Latino
Multi-Racial
Native Hawaiian/Pacific Islander

Languages*

Please list any language that you are familiar with other than English in the 1st column below. Then indicate your ability to read, write, and speak the language on a scale of 1-5, with 5 being fluent.

Language	Read	Speak	Write

Transportation

PARENT/GUARDIAN EMERGENCY CONTACT INFORMATION

Name*

Email Address*

Phone Number*

Relationship*

CLIENT INFORMATION

Name*

Date of Birth*

Social Security Number*

Address*

Email Address*

Home Phone*

Cell Phone*

Work Phone*

Gender*

Female
Male
Prefer not to say
Other

Ethnicity*

Please select your ethnicity.

African-American/Black
American Indian/Alaska Native
Asian
Bi-Racial
Caucasian/White
Hispanic/Latino
Multi-Racial
Native Hawaiian/Pacific Islander

Education*

Please indicate the highest level of education you have achieved.

Other

Please enter your gender.

Languages*

Please list any language that you are familiar with other than English in the 1st column below. Then indicate your ability to read, write, and speak the language on a scale of 1-5, with 5 being fluent.

Language	Read	Speak	Write

Transportation

CLIENT EMERGENCY CONTACT INFORMATION

Name*

Email Address*

Phone Number*

Relationship*

Client Intake Form

Step 1 of 2

GENERAL INFORMATION

PARENT/GUARDIAN INFORMATION INFORMATION

PARENT/GUARDIAN EMERGENCY CONTACT INFORMATION

CLIENT INFORMATION

CLIENT EMERGENCY CONTACT INFORMATION

Open Heart Leaders Questionnaire