A 501(c)(3) Non-Profit Organization | Georgia, United States
info@onramp-independence.org | (555) 123-4567

Form ORI-CIF-01
Rev. 2025

Client Intake Form

Completed by or on behalf of new clients seeking OnRamp services. All sections required unless marked optional.

Confidential: Information provided on this form is kept strictly confidential and used only to connect you with appropriate services. You have the right to review, correct, or request deletion of your information at any time.

1. Personal Information

Full Legal Name *

Preferred Name / Goes By

Date of Birth *

Age

Gender Identity (Optional)

Pronouns (Optional)

Race / Ethnicity (Optional)

Primary Language

2. Contact Information

Current Mailing Address *

City

State

ZIP Code

Cell Phone *

Alternate Phone

Email Address

Preferred Method of Contact

Call Text / SMS Email In Person

3. Current Living Situation

Current Housing Status *

Foster home Group home / residential facility Own apartment / housing Transitional housing program Couch surfing / unstable Homeless / unsheltered Other: ___________________

Currently in Foster Care System?

Yes, currently in care Aged out / formerly in care Never been in foster care

If aged out, year of exit

County / State of Care

Case Manager / Worker Name

4. Education & Employment

Highest Education Level Completed

Some middle school Some high school High school diploma / GED Some college / trade school Associate's degree Bachelor's degree or higher

Current School / Program (if enrolled)

Current Employment Status

Employed full-time Employed part-time Seeking employment Not seeking employment

5. Needs & Goals

In your own words, what is the most pressing challenge you are facing right now?

What is your main goal in connecting with OnRamp To Independence?

6. Emergency Contact

Emergency Contact Name *

Relationship

Phone (Primary) *

Phone (Alternate)

7. Referral Information

How did you hear about OnRamp To Independence?

Case manager / social worker School / teacher / counselor Another organization Friend or family member Social media / internet Community event / flyer Other: ___________________

If referred by a person or organization, please provide their name and contact info:

8. Consent & Signature

By signing below, I certify that the information provided in this form is accurate and complete to the best of my knowledge. I understand that OnRamp To Independence will use this information to determine appropriate services and to communicate with me about those services. I acknowledge that my information is kept confidential in accordance with the OnRamp To Independence Privacy Policy and applicable law.

I understand I may revoke consent and/or withdraw from services at any time by notifying OnRamp To Independence in writing or by contacting info@onramp-independence.org.

Signature of Client *

Date *

If the client is under 18, a parent or legal guardian must also sign below.

Signature of Parent / Guardian

Relationship to Client

Date

For Office Use Only

Date Received

Client ID

Intake Completed By

Notes

CONFIDENTIAL — OnRamp To Independence Client Record