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Adult Health Intake

  1. Public Health Intake

  2. Client: DD, PCA, EW / AC, CADI, CAC, BI

  3. Description of Referral

  4. Sex

  5. Veteran

  6. HOME CARE ONLY (if on MA do not need to financial information)

  7. OTHER INFORMATION (to be filled out by county intake worker)

  8. Certified Disabled

  9. Type of Disability Certification (select one)

  10. Prepaid Health Plan

  11. Previously known to Social Services / Public Health

  12. For information and referral staff only:

  13. Leave This Blank:

  14. This field is not part of the form submission.