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H.A.N.D.Help At No Discrepancy

Community Support

H.A.N.D. Community Intake Form

This form helps H.A.N.D. understand what support you may need so we can connect you with the right professional, program, or community resource.

Your privacy matters. This form collects sensitive personal and health information. Your responses are handled with care and used only to connect you with appropriate support. H.A.N.D. will not share your information without your consent.

If this is an emergency — do not wait:

🚨 Call 911📞 Call or Text 988💬 Text HOME to 741741
1

Personal Information

What would you like to be called?

Emergency Contact

2

Why You're Here Today

In your own words — there's no wrong answer.

3

Mental Health History

This helps us understand your background so we can connect you with the most appropriate support.

Have you received mental health services before?

Are you currently seeing a therapist, counselor, or mental health provider?

Have you ever been hospitalized for mental health reasons?

Do you have a current mental health diagnosis?

Are you currently taking any psychiatric or mental health medications?

4

Mental Health

The following questions ask about emotional well-being and personal safety. We understand that these topics may be difficult to discuss. Your responses will help us better understand what support or resources may be helpful to you.

Depression Screen

Over the past two weeks, how often have you been bothered by the following?

Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?

If this is an emergency or you are in immediate danger, call 911 now.

If you are experiencing a mental health crisis, call or text 988. You can also text HOME to 741741. H.A.N.D. is not an emergency service.

Are you safe at home?

Do you feel like harming yourself?

Have you ever attempted suicide?

Have you ever engaged in self-injury that was not intended as a suicide attempt?(e.g. cutting, burning)

Do you feel like harming others?

5

Community & Support Needs

Let us know what areas of support interest you. All fields are optional.

1.Do you need in-home care?

If yes, please describe below.

2.Are you interested in moving?

If yes, please describe below.

3.Are you interested in shared living?

If yes, please share your price range and details below.

4.Are you interested in counseling?

5.Are you interested in group sessions?

6.Are you interested in volunteering?

7.Are you interested in work and/or making extra money?

If yes, please check any that apply and share details below.

• What would help most? Select all that apply.

8.Are you interested in workshops?

9.Are you interested in self-care?

10.Are you interested in detoxifying your body?

6

Health & Wellness

1.Do you have allergies?

If yes, please describe below.

4.Do you have any existing health conditions or diagnoses?

If yes, please describe below.

5.Are you taking any medications or supplements?

If yes, please describe below.

6.Do you have any open wounds?

If yes, please describe below.

7.Have you recently undergone any medical procedures or surgeries?

If yes, please describe below.

Alcohol & Tobacco Use

AUDIT-C — a brief, validated screening tool used across community health settings. All questions are optional.

7

Financial & Coverage

H.A.N.D. can connect you with resources related to coverage, planning, and financial protection.

1.Do you have medical / dental / vision coverage?

2.Do you have a will or trust?

3.Do you plan on traveling 75 miles outside your area or the United States?

4.Do you have international coverage?

5.Do you have final expense coverage?

8

Additional Information

9

Consent & Acknowledgments

Please read and accept all four statements before submitting. All are required.

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This form's secure data pipeline is under review before activation. Clicking "Submit" will not transmit your data — you will be shown direct contact options instead.

All four consent statements are required before submitting.

In crisis? Help is available 24/7 — you don't need this form.

Call or Text 988·Text HOME to 741741·911