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Client Intake Questionnaire
SECTION 1: PERSONAL INFORMATION
1. Full legal name
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2. Other names you have used (include dates for each)
3. Date of birth
*
4. Place of birth
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5. Current home address (street, city, state, zip code)
*
6. How long have you lived at your current address?
*
7. Previous addresses for the past 5 years (include dates lived at each)
8. Primary phone number
*
9. Secondary phone number (if any)
10. Email address
*
11. Preferred method of contact
*
12. What languages do you speak fluently?
*
13. What languages can you read and write fluently?
*
14. Do you speak English with ease? If not, what language and dialect do you normally use?
*
15. Do you read and write English with ease? If not, what language and dialect do you normally use?
*
16. At the time of the incident, did you have a valid driver's license?
*
17. If yes, provide: State of issuance, license number, license type, date of issuance, any restrictions
18. Did you have any other permits or licenses for motor vehicle operation at the time of the incident? If yes, describe
19. List all schools or training institutions attended beginning with high school
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20. Have you ever been convicted of a felony? If yes, provide details
*
21. Current employer or business name, address, and phone number
*
22. Your current job title
*
23. Date your current employment began
24. Employment status
*
25. List all employers or businesses you worked for in the past 5 years
*
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