Get In Intake Assessment Std Clinic - Fort Wayne-allen County 2013-2026

Filling out the IN Intake Assessment form online is an essential step for accessing healthcare services at the STD Clinic in Fort Wayne-Allen County. This guide provides clear instructions on completing the assessment efficiently and accurately.

Follow the steps to successfully complete your online intake assessment.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter today's date in the designated field to indicate the date of your assessment.
3. Indicate whether you have visited the clinic before by selecting either 'Yes' or 'No'.
4. Fill in your Social Security number in the provided section, if applicable.
5. Complete your first name, middle initial, last name, date of birth, and current age in the respective fields.
6. Input your address, including apartment number (if applicable), city, county, state, and zip code.
7. Select your country of birth from the options provided or write in another country if it's not listed.
8. Choose your gender by selecting the appropriate option. Ensure to select the option that you identify with.
9. Provide your alternate phone number and specify if it is acceptable to leave a message.
10. Input your home, cell, and work phone numbers, indicating whether messages may be left for each.
11. Enter your email address and indicate your preferred method of contact, either phone or email.
12. Specify whether it is acceptable to call or send an email reminder of your appointment.
13. Provide details regarding your employment status and place of employment or school.
14. Select your marital status from the provided options.
15. Indicate your current yearly individual income.
16. If applicable, choose your health insurance provider from the list of options.
17. Select your primary language and any other language preferences.
18. Indicate your race and ethnicity by selecting the appropriate options.
19. State the reason for your visit in the corresponding field.
20. Review all the information you have entered for accuracy before signing the document.
21. Sign the form to confirm that the information is true to the best of your knowledge.
22. Once completed, save your changes, and you can choose to download, print, or share the form as needed.

Take the next step in your healthcare journey by completing the online intake assessment today.