Rama Cares Intake Form

Supporting People in Crisis, Mental Health Challenges, and Veterans in Need

A. Personal Information

Full Name

Date of Birth (DD/MM/YYYY)

Gender

Male

Female

Non-binary

Prefer not to say

Phone Number

Email Address

Current Address (or last known)

Medicaid Number

Provider Name (Medicaid attached to)

B. Background Information

Are you a U.S. Military Veteran?

Yes

Current Living Situation:

Homeless

Temporary Shelter

Staying with Family/Friends

Own/Rent Home

Other:

Do you have any children or dependents?

Yes

If yes, how many?

C. Areas of Need

Mental Health Support

Emergency Housing

Substance Abuse Recovery

Food Assistance

Medical Care

Job Placement / Skills Training

Transportation

Legal Support

Spiritual Counseling

Other:

D. Priority Level

How urgent is your current situation?

Emergency (Immediate danger or crisis)

Urgent (Need help within 24–72 hours)

Moderate (Need support soon)

Low (Ongoing support or resources)

Please describe your current situation briefly

E. Consent & Contact

May we contact you for follow-up and support?

Yes

Preferred method of contact:

Phone

Text

In-person Meeting

F. Confidentiality Agreement

By submitting this form, you consent to Rama Cares using this information solely for the purpose of providing assistance and support. Your information will be kept confidential and secure.

Signature (if printed)

Date (DD/MM/YYYY)

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