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Outreach Intake Form (Adult)

Outreach Intake Form

(Adults / Young Adults Over the Age of 18)

First Name

Last Name

Date of Birth

Organization Name

Address 1

Address 2

City

State

ZIP

Email Address

Home Phone

Cell Phone

How old are you?

Would you consider yourself to be an introvert, extrovert, or mix of both?

Introvert Extrovert Mix of Both

What interests do you have? (sports, hobbies, etc)

In the past few years, have you experienced any major life-changing transitions or issues?

Do you like dogs and if so, do you believe that spending time with dogs can be therapeutic in any way for conditions that you may be experiencing?

Yes No

Have you been in close physical contact with anyone who tested positive for COVID-19 or has exhibited COVID-19 symptoms in the past 2 weeks?

Yes No

Have you exhibited any of the following symptoms of COVID-19 in the last 48 hours?

Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New/recent loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea NONE OF THE ABOVE

Are you currently waiting on the results of a COVID-19 test for you?

Yes No

Have you traveled in the past 10 days?

Yes No

Agreement

I hereby state that my answers to the questions provided above are true and correct to the fullest extent of my knowledge, information and belief.

Printed Name of Van of Promise Patient

Agreement

I hereby consent to participation in activities orchestrated by “The Van of Promise” with the “Life Path Institute” and/or the employees of either entity.

Signature of Van of Promise Patient (sign with finger, mouse, or trackpad)

Printed Name of Van of Promise Patient

CONTACT

(240)-498-8176

Lifepathinst@gmail.com

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