Tell us how we can support you.

Complete only what you feel comfortable sharing. This editable packet is designed to help us understand your priorities before an introductory consultation.

Your information stays with you.This form does not submit or store information online. Complete it, then print or save it as a PDF for your records.

1. Client Information

Full legal namePreferred nameDate of birthPrimary languageHome addressCityStateZIP codePhone numberEmail addressPreferred contact methodBest time to contact

2. Emergency Contact

Contact nameRelationshipPhone numberAlternate phone

3. Support Requested

Check all services you would like to discuss.

What brings you to Standing in the Gap Advocacy?What would you most like help accomplishing?

4. Known Formal Diagnoses

This section is optional. Please share only what you feel comfortable providing.

Please list any known formal medical, mental health, developmental, or other diagnoses.

5. Current Providers & Supports

Primary care providerClinic or organizationCase manager or coordinatorHealth plan / insurance

Other agencies, providers, or natural supports involved

6. Accessibility & Communication

Please describe any accessibility, communication, cultural, mobility, sensory, or scheduling needs we should know about.

7. Client Acknowledgment

I understand that this intake form helps Standing in the Gap Advocacy learn about my needs. Completing this form does not create a medical, legal, or emergency-services relationship. Advocacy services do not replace medical, legal, or emergency care.

Client or representative nameDate