ESM Release of Information:  ⁭ Yes  ⁭ No

Enrollment Date:               /            /
                        mm          dd          yyyy

Provider ID:

ESM Client ID:                                                          

                                                          Intake Form                            House of Correction  

                                                                         ALL QUESTIONS MARKED WITH A  MUST BE COMPLETED.	
  	1. First  Name:	Middle Initial:	Last Name: 	Suffix:	
	2. Highest Grade Completed:	
		Not of school age		High school diploma/GED		College degree or higher		No formal education	
		Some schooling, no high school		Some college		Other credential (degree, certificate)		Unknown	
		Some high school		Associates degree					
	3. Gender:       Male  	Female  	Transgender  	4. Birth Date:	       /          /
mm    dd      yyyy	
	5. SSN:	If  unknown, enter 999999999 	
PERSONAL INFORMATION>ADDRESS 
	6a. Address Type:	Home    Near Homeless    Homeless     	Refers to address type and address PRIOR to incarceration.  
Please refer to the "Address Type Decision Tree" in the HOC Intake Manual to determine Address Type.	
 If Address Type is “Homeless”, only enter the city/town and zip code where client is usually homeless. Do not use the Institution’s city/town/zip.	
	 Street Address:	 	Unit:	
	 City/Town:	        	State:		Zip code:    	
	6b. Is this your Primary Address?  Yes   		
 ALTERNATIVE NAME Section
	If client has an alternative name, complete the following:				
	7a. First  Name:	Middle Initial:	Last Name: 		
            7b. Name Type:	 Alias    Nickname    Known by        Married Name     Maiden Name      Name at Birth        Prior Marriage Name 	
DEMOGRAPHICS>CULTURAL CHARACTERISTICS
	8a. Are you Spanish/ Hispanic/Latino?	Yes      No                                                    	
 If ‘yes’ to Question 8a, complete Question 8b.                               If ‘no’ to Question 8a, go to Question 9	
	
8b. Which of the following ethnicities best describes you?

______ Central American                                    ______  Mexican, Mexican American, Chicano              ______  South American
______ Cuban                                                     ______  Puerto Rican                                                      ______  Unknown
______ Dominican                                               ______  Salvadoran                                                        ______  Other, specify _____________________    
                                                                                                                               	
  If ‘no’ to Question 8a, Select one from below	
	9.  What is your primary Ethnicity/Ancestry?  (select one only)                                                                                                                 	
		African		Chinese		Latin American Indian	
		African American		Eastern European		Middle Eastern	

Client Demographics				 Intake Form

		American		European		Portuguese	
		Asian Indian		Filipino		Russian	
		Brazilian		Haitian		Thai	
		Cambodian		Japanese		Vietnamese	
		Cape Verdean		Korean		Unknown	
		Caribbean Islander		Laotian  		Other ,specify		

	10. What is your race?  (check all that apply)                                                                                                         	
		American Indian/Alaskan Indian		Native Hawaiian or Pacific Islander		Unknown	
		Asian		White		Refused	
		Black, African American		Other, specify:			
							
	11. In what language do you prefer to read or discuss health related materials?	
		American Sign Language		Haitian Creole		Russian	
		Cambodian (Khmer)		Hmong		Spanish	
		Cape Verdean Creole		Korean		Vietnamese	
		Chinese		Laotian 		Other, specify ______________________	
		English		Portuguese				

HOUSEHOLD CHARACTERISTICS Section

12. Number of Adults in Household:         

1

 	
	
13. Number of Children Living in Household:          

0

	
14. Client Income:   $

0

	15. Marital Status:        Never Married         Married        Divorced         Widowed        Separated       Significant Partnership Rlat.	

INSURANCE Section (Data Entry:  To get to Insurance Section, Return to Face Sheet and select Insurance link on left side of screen.)
       	16. Insurance Type:	 Uninsured