Intake

Name*
First Last
Gender
Age*
Date of Birth
MM slash DD slash YYYY
Phone where you can be reached
Email/ Facebook
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency contact ( if you are 16 -17 years old please put parent or gaudian)
Name phone # Relationship
Where are you currently living?*
- With Parent or Relative
- With Foster Family
- With Friends or Wherever I Can
- I have my own Place
- I am currently homeless
Date of First Contact
MM slash DD slash YYYY
How was Initial made Contact?
- Website
- Facebook
- Twitter
- Walk-In
- Phone
- Referal
Reason for Contact
How did you hear about ReMix?
- Facebook
- Twitter
- Referal
- Radio
- Other Please Explain Below (flyer,Friend, school)
Other please explain
Education
Highest Grade Completed
School Goals?
Employment Status
- I am working full time
- I am working part time
- I worked in the pass
- I have never worked
Employment Goals
Are you currently recieving:
- Cash assistance
- Food Assistance
- Medicaid
Do you have a history of substance abuse?
- Yes
- No
Age of first use?
Are you still using?
- Yes
- No
Do you have any probational/court involvement?
- Yes
- No
Other comments/concerns
Phone
This field is for validation purposes and should be left unchanged.