Roots CSI Intake Form
Please answer all questions on this form, so that we can best assist you. A Roots CSI representative will reach out to you with 1-3 days. All information shared in this form is confidential and strictly for record-keeping purposes. No information will be shared with other organizations without your permission. We have no affiliation with data collectors. 
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Full name *
First and last name. Please do not type in a nickname or alias. 
Date of birth *
MM
/
DD
/
YYYY
Phone number *
Email *
Address *
Housing type *
Homelessness has many faces. For reference, unsheltered means residing in a place not meant for human habitation, such as cars, parks, on the street, abandoned buildings, wooded areas, underpasses, etc.
Highest level of education *
Employment *
Known health conditions
Please list any physical health or mental health conditions known. Please do not share any details about treatment or medication. 
Medical insurance *
Assistance you are seeking *
Check all that apply.
Required
Best time to reach you *
Check all that apply.
Morning (9:00-11:30)
Afternoon (12:00-3:00)
Evening (4:00-6:00)
Monday
Tuesday
Wednesday
Thursday
Friday
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