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AIM INTAKE FORM

To inquire about AIM services or to refer a prospective client please fill out the form below.

Your name and affiliation with the Prospective Client
First Name, MI

Last Name

Title

Company


Please enter your contact info:
Address

City, State, Zip

Day Telephone

Cell\Evening Phone

Emergency Contact Phone

Emergency Contact Person


PLEASE TELL US ABOUT THE PROSPECTIVE CLIENT

First Name, MI

Last Name

Issue

Client Age:

Current Placement:

Race\Ethnicity










Tell us about the Child(ren) of the Prospective Client

Children under 18


Prospective
Client's Child is
Placed in







Prospective Client's Child(ren)
has System Involvement with




Guardian


Housing Difficulties:



Is the Prospective Client incarcerated? If so (or if not), where are they?


Does the Prospective
Client have a Past Record
of Incarceration?





 

Does the Prospective Client Have a History of the Following:
Suicide?

Homocide?

Other
Please Describe
 
Substance Abuse


Sex Abuse


Physical Abuse


Fire Setting


Anger Issues








THANK YOU FOR YOUR REFERRAL


Note: To complete this referral, please click yes to automated the requests after clicking the Submit button.

 
     
 

 
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