UNIVERSAL INTAKE FORM 1 - css lacounty 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the 'Applicant Name' section, including your last name, first name, and middle initial. Fill in your home address, city, state, and zip code.
3. Indicate your birth date and gender. You can also specify if you decline to state this information.
4. Complete the 'Client Demographics' section by selecting your race and ethnicity from the provided options. This helps in understanding the diverse needs of clients.
5. In the 'Emergency Contact' section, provide details for someone who can be reached in case of an emergency. Include their name, relationship to you, and contact information.
6. Proceed to the 'Financial/Benefits' section where you will indicate if you receive Social Security benefits or Medi-Cal. Fill out any optional fields as necessary.
7. Finally, review all sections for accuracy before signing at the bottom of the form to certify that all information is true and complete.

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