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Client Intake Formjbrooksctbla2021-03-24T10:39:59-07:00

Client Intake Form

Step 1 of 2

50%

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*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email Address*
Enter Email Confirm Email
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
- Personal Car
- Public Transit
- Ride Bicycle
- Taxi/Ride Share
- Walk
PARENT/GUARDIAN EMERGENCY CONTACT INFORMATION
Name*
First Last
Email Address*
Enter Email Confirm Email
Phone Number*
Relationship*
CLIENT INFORMATION
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email Address*
Enter Email Confirm Email
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.
- Grade 1-5
- Grade 6-11
- High School Diploma
- Bachelor's Degree
- Master's Degree
- Doctorate Degree
- Technical/Vocational School Graduate
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
- Personal Car
- Public Transit
- Ride Bicycle
- Taxi/Ride Share
- Walk
CLIENT EMERGENCY CONTACT INFORMATION
Name*
First Last
Email Address*
Enter Email Confirm Email
Phone Number*
Relationship*

Date
MM slash DD slash YYYY
Open Heart Leaders Questionnaire
Are you filling this application out for someone under the age of 18?*
- Yes
- No
Filling out the OHL Questionnaire is not required for children under the age of 18.
Please complete the questionnaire as the client.
How did you hear about us?*
- Friend
- Other Organization
- Facebook
- LinkedIn
- Twitter
- Instagram
Other Organization*
What is your ethnicity?*
- African-American/Black
- American Indian/Alaska Native
- Asian
- Bi-Racial
- Caucasian/White
- Hispanic/Latino
- Multi-Racial
- Native Hawaiian/Pacific Islander
Are you a student?*
- No
- Part-time
- Full-time
Are you interested in continuing your education?*
- Yes
- No
What is your household size?*
How many kids (under 18)? How many adults (18 +)?
Are you currently seeking employment?*
- Yes
- No
Are you currently employed?*
- Yes
- No
What is your occupation?*
I am employed*
- Full-time
- Part-time
- Seasonally
What is your annual household income?*
- Less than $10,000
- $10,000 to $29,999
- $30,000 to $49,999
- $50,000 to $79,999
- $80,000 to $99,999
- More than $100,000
Have you ever experienced or currently experiencing any problems with (check all that apply)*
- Drug Abuse
- Alcohol Abuse
- Homelessness
- N/A
Have you ever been a victim of (check all that apply)*
- Physical Abuse (any physical injury inflicted on a person by other than accidental means)
- Sexual Abuse (any unwanted means of sexual activity through force, threats or a person not being able to give consent)
- Emotional Abuse (any attempts to frighten, control or isolate a person )
- Verbal Abuse (any act of violence that is in the form of speech that negatively affects a person)
- N/A
Have you ever been a witness of (check all that apply)*
- Physical Abuse (any physical injury inflicted on a person by other than accidental means)
- Sexual Abuse (any unwanted means of sexual activity through force, threats or a person not being able to give consent)
- Emotional Abuse (any attempts to frighten, control or isolate a person )
- Verbal Abuse (any act of violence that is in the form of speech that negatively affects a person)
- N/A
Have you ever been a perpetrator (a person who committed) of (check all that apply)*
- Physical Abuse (any physical injury inflicted on a person by other than accidental means)
- Sexual Abuse (any unwanted means of sexual activity through force, threats or a person not being able to give consent)
- Emotional Abuse (any attempts to frighten, control or isolate a person )
- Verbal Abuse (any act of violence that is in the form of speech that negatively affects a person)
- N/A
Have you previously received any type of mental health services for (check all that apply)*
- Therapy
- Counseling
- Life Coaching
- Other
- No
Have you ever been incarcerated?*
- Yes
- No
Has someone in your family been incarcerated?*
- Yes
- No
Are you currently on parole or probation?*
- Yes
- No
Is someone in your family currently on parole or probation?*
- Yes
- No
Are you or someone you know involved in any gang-related activity?*
- Yes
- No
Are you partaking in any of the services below? (check all that apply)*
- CalFresh
- Welfare
- Medical
- Section 8
- Public or Subsidized Housing Assistance
- N/A
Are you interested in learning English, Spanish or ASL (If yes, check all that Apply)?*
- ASL
- English
- Spanish
- N/A
Do you currently have insurance for (check all that apply)*
- Medical
- Dental
- Vision
- No Insurance
Are you or someone in your family struggling or trying to obtain naturalization?*
- Yes
- No
Are you in need of any legal assistance/services?*
- Yes
- No

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Step 1 of 2

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CLASS SELECTION
Open Heart Leaders Course*
Please select the class you would like to attend.
PERSONAL INFORMATION
Name*
First Last
Email*
Enter Email Confirm Email
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone*
Date of Birth*
MM slash DD slash YYYY

CART
Beginners American Sign Language
Includes
*16 Classes Over 8 Weeks (9/07/2021-10/28/2021)
*ASL Book
*ASL Flashcards
*Personal Notebook
*Special Gift & Certification Upon Completion of Course
Price:
DISCOUNT CODE
Discount Code
TOTAL
Total
$0.00
PAYMENT INFORMATION
Credit Card
Card Details
Cardholder Name
Billing Address*
Please enter your credit card billing address.

Street Address City State / Province / Region ZIP / Postal Code Country
Email Address*
Please enter the email address where you would like to receive your receipt.
Enter Email Confirm Email
CAPTCHA

Name*
First Last
Email*
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