SPA - New Client Form

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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.

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

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?)

Is there anything else you would like us to know? Additional Comments?

Submit

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