ADULT/YOUTH SERVICES, LLC.
320 N Academy Blvd Suite 205
Colorado Springs, CO 80909
INITIAL CLIENT INTAKE
INTAKE DATE:
START DATE:
LAST NAME:
FIRST NAME, M INTIAL:
MAILING ADDRESS:
PHONE(H):
CITY/STATE/ZIP:
PHONE(W):
EMPLOYER:
PHONE(ALT):
ADDRESS:
EMAIL:
CITY/STATE/ZIP:
SSN:
DATE OF BIRTH:
AGE IN INTAKE:
SEX:
MALE
FEMALE
RACE:(CIRCLE ONE) "Other - To include mixed race and any unllsted race."
WHITE
BLACK
HISPANIC
ASIAN
PACFIC ISLANDER
OTHER
RELIGIOUS REFRENCE:
HAIR COLOR:
IDENTIFYING MARKS:
EYE COLOR:
LEGAL INFORMATION
CHARGE:
BAC:
DISTRICT:
CASE NUMBER:
JUDGE:
ALCOHOL EVAULATOR:
PROBATION OFFICER:
REFERD BY:
ATTORNEY:
PLEASE LIST ANY PREVIOUS CHARGE
EMERGENCY CONTACT
NAME:
REALTIONSHIP:
ADDRESS:
PHONE:
PLEASE INITIAL GIVING AYS TO CONTACT THIS PERSON IN CASE OF AN EMERGENCY
WORK/EDUCATION/INFORMATION
PROFESSION/ e s of work
Years in current field
Years in other field
Years of formal education
Work / education goals:
Did you graduate from high school?
From college?
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