Transition to Success Client Intake Form

Please complete this intake and assessment to enroll in the Transition to Success (TTS) program. A TTS Coach will reach out to you within 2 business days.

*If you need immediate help, please call one of the following:

211 for community resources
988 for mental health needs
911 for life and safety concerns

Are you completing this intake for yourself or someone else?

MyselfSomeone Else

Name of the Person to Enroll in TTS:*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

May we leave a voicemail at this number?*

YesNo

May we text this number?*

YesNo

Date of Birth*

Date

Gender*

Race / Ethnicity*

Currently Homeless?

YesNo

Address:*

Street or Mailing Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please rate each Life Area on a scale of 1 to 5. Select 0 if this Life Area does not apply.*

	1 - In Crisis	2 - Need Help Soon	3 - Could Be Doing Better	4 - Doing OK	5 - Doing Really Well	0 -Does Not Apply to Me
Food
Housing
Money
Mental Health
Drugs / Alcohol
Health Care / Insurance
Safety
Transportation
Disabilities
Life Skills
Work
Legal
Child Care
Adult Education
Parenting
Children Education
Community Involvement
Support from Family & Friends
Budgeting
Discrimination / Racism
Internet / Phone
Dental Care
ID / Birth Certificate

What is your main dream for your life right now?

Please ask questions or provide additional information that the TTS Coach should know about you:

Today's Date*

Date

Helpline Center Network of Care Consent:

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. Please review the full consent here. You understand that your personal information will only be disclosed in accordance with applicable South Dakota laws.

Do you consent to share your information with the Helpline Center Network of Care?

YesNo

Electronic signature: Please type your full name

First and Last Name

Helpline Center Network of Care Consent Instructions:

You are completing this form for another person who must complete the Helpline Center Network of Care consent. The person you are enrolling will receive an email at the email address entered above to sign the consent document.

Please let the person you are enrolling know that they will automatically receive a consent form to their email after you submit this form.

Name of person completing this form:

First NameLast Name

Email of the person completing this form:

example@example.com

Organization:

Transition to Success Intake Form