Fall Prevention Intake Form

Fall Prevention Intake Form
Referred by:*
Name of individual making referral*

First NameLast Name
Phone Number of individual making referral *
Please enter a valid phone number.
Is the individual aware of this referral?*

YesNo
Name of individual in need of services *

First NameLast Name
Phone Number for individual in need of services*
Please enter a valid phone number.
Address for individual in need of services *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the best time to contact the individual in need of services*

MorningAfternoonEvening
Can we leave a voicemail?*

YesNo
Can we send a text message?*

YesNo
Describe fall history*
If none, put N/A
To help us better understand more about the individual needing services, help provide us with some demographic information.
Birth Date*

MonthDayYear
Date
What is your Gender?*

MaleFemaleTransgenderNon-BinaryOther
What is your Race?*

AsianBlack / African AmericanMixed RaceNative American or Alaska NativeNative Hawaiian or Other Pacific IslanderWhite / CaucasianDeclinedOther
What is your Ethnicity?*

Hispanic or LatinoNot Hispanic or LatinoDeclined
Are you a Veteran?*

YesNo
The Helpline Center is required to collect your personal information as part of the Helpline Center Network of Care (HCNC).

You understand the collection and use of all your personal information is protected by strict standards of confidentiality as outlined in writing in the Helpline Center Network of Care Policies and Procedures and that this agency cannot provide specific legal advice regarding your rights on any of this information. You also understand that your personal information will only be disclosed in accordance with applicable South Dakota laws.
Do you agree?*

YesNo
Staff who filled out this form:*

First NameLast Name
Should be Empty:

Fall Prevention Intake Form

To help us better understand more about the individual needing services, help provide us with some demographic information.