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UNIVERSAL INTAKE FORM 1 - css lacounty 2026
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- Click ‘Get Form’ to open it in the editor.
- 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.
- Indicate your birth date and gender. You can also specify if you decline to state this information.
- Complete the 'Client Demographics' section by selecting your race and ethnicity from the provided options. This helps in understanding the diverse needs of clients.
- 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.
- 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.
- 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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