H.A.N.D. logo
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 may be used to evaluate your service needs, coordinate referrals, maintain organizational records, and respond to safety concerns. Information is handled in accordance with H.A.N.D.'s privacy practices and applicable law.

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

Optional
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?

Have you ever been diagnosed with a mental health condition?

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.

8.Are you interested in workshops?

9.Are you interested in self-care?

10.Are you interested in detoxifying your body?

6

Health & Wellness

Answer only what feels relevant. Additional detail helps us make better referrals, but all fields are optional.

1.Do you have allergies?

If yes, please describe below.

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

If yes, please describe below.

Alcohol & Tobacco

Optional — answer only if relevant to the support you're seeking.

Do you currently use alcohol or tobacco products?

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?

Are you interested in financial planning or coverage resources?

Wills, estate planning, travel coverage, final expense

8

Additional Information

9

Consent & Acknowledgments

Please review and accept all four statements before submitting. Tap "Read full statement" to see the complete text.

🔒 Secure submission being finalized

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