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TEAM PURSUIT

Team Pursuit

Community Resource Initial Intake Form

1. Basic Information

Full Name

Phone Number *

Use the same phone number you received this SMS/email on.

Date Of Birth

Street Address

Date Applying

Zip Code

Which Service Needed? *

Which Service Needed?

Provide other details.

2. Tell Us About You & Your Family

Tell us about yourself and your family/household

3. Household Information

Who lives in your home? (names/ages/relationship)

Number of adults / children

Are you the primary caregiver?

Yes

No

4. Employment & Income

Are you currently employed?

Yes

No

Specify employment type

Full-time

Part-time

Temporary

5. Immediate Needs

Immediate Needs (Select all that apply)

6. Current Situation & Safety

Do you feel safe where you are living?

Yes

No

Are you currently in crisis?

Yes

No

Do you have thoughts of harming yourself or others?

Yes

No

If yes, please explain

Additional Information (If Not Covered Above)

I have read and agree to Team Pursuit's Privacy Policy and Terms and Conditions. I understand that by checking this box and submitting this form, I am providing my electronic signature and consent. If I am registering a minor child, I confirm I am their parent or legal guardian and am providing consent on their behalf.

I consent to receive text messages from Team Pursuit regarding programs, events, and community updates. Message and data rates may apply. Reply STOP to unsubscribe.

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