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SPA - New Client Form
Please fill out and submit this form each time you have a new client. This will help us keep track of the demographics that we are serving and easily submit data for grants. Thank you so much for your help.
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Email
*
Your email
Age
0-9
10-14
15-24
25-44
45-64
65-74
75 and older
Unknown
Clear selection
Gender
Male
Female
Transgender Man
Transgender Woman
Non-Binary
Unknown
Other:
Clear selection
Sexual Orientation
Straight
Lesbian
Gay
Bisexual
Transgender
Queer or Questioning
Unknown
Other:
Clear selection
Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Unknown
Other:
Clear selection
Method of Contact
In Person
Phone Call
Email
Video Call (FaceTime, Zoom, etc...)
Text Message
Other:
Clear selection
What resources were they referred to, if any?
Confidential & Complimentary Counseling Program
Addiction Recovery
Advocates
The Health Partnership
Northwest Colorado Health
Other:
Clear selection
Is this client a REPS referral or did you connect with this client for reasons unassociated with REPS? (i.e. how were you connected/referred to this client?)
Your answer
Is there anything else you would like us to know? Additional Comments?
Your answer
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