Get 5.8.1 Outreach Intake Form Name: Date: / / ... - Cdc 2016-2025

The 5.8.1 Outreach Intake Form is an essential tool for individuals seeking outreach and prevention services. This guide will provide you with clear instructions on how to complete the form effectively and ensure that you submit all necessary information.

Follow the steps to fill out the form efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your full name in the designated field labeled 'Name'. This is crucial for identifying you in the system.
3. Next, fill in the 'Date' field with the current date in the format of month, day, and year.
4. In the 'Address' field, provide your complete residential address. Make sure to include street address, city, state, and zip code for accuracy.
5. Input your phone number in the format (area code) number, ensuring it is a valid contact for further communication.
6. Complete the 'Date of Birth' section with your birth date. It's essential to use the correct date format as specified.
7. Select your gender by marking the appropriate box for Male, Female, or Transgender.
8. Fill in your ethnicity where requested, as this information may be relevant for the services provided.
9. Provide an emergency contact person's name and their phone number. This contact will be used if immediate access to a support person is necessary.
10. Indicate your insurance status by selecting the appropriate option: Private, Medicaid, Medicare, or Fort Bend County Card.
11. Describe your medical status briefly in the designated field to assist the service providers in understanding your needs.
12. If applicable, list any psychological conditions in the appropriate section. This information is vital for tailoring services to your situation.
13. Review the 'Consent for Services' section. You will need to acknowledge your understanding of the services, confidentiality, and liability agreements by writing your name and signing.
14. Once all fields are completed, review your entries for accuracy. After ensuring everything is correct, save your changes. You can then download, print, or share the form as required.

Complete the 5.8.1 Outreach Intake Form online to start your journey towards accessing essential services.