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SMART Center Intake Form
Please complete the fields below.
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What is your first name?
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What is your last name?
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What is your age?
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What is your Date of Birth?
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What is your Child's Date of Birth?
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Please specify your ethnicity.
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What is your email?
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What is your phone number?
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What is your address?
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What zip code do you reside in?
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Were you referred to us?
Yes
No
If yes, by whom: (Ex: Doctor, School, Church Health, etc.)
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We offer Spanish-language interpretation services at no charge. Do you need interpreter services?
Yes
No
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What is your primary language?
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How would you like to meet?
Meet In Person on Campus
Meet Virtual
No Preference
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What concerns can we help you with today?
Food Insecurity
Housing Insecurity
Mental and Behavioral Assessment
Counseling/Therapy Services
Linking to Other Services
Advocacy
Organizational Training on Technology
Contracting for Telehealth Services for My Organization
Other
If other, please describe.
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Current or previous diagnosis?
Yes
No
If yes, please describe.
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Have you been in counseling in the past?
Yes
No
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Are you receiving any other services at this time?
Yes
No
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What is the best way we can get in touch with you?
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Are you currently pregnant?
Yes
No
If yes, how many weeks pregnant are you?
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Have you experienced violence with a partner in the past year? (This can include emotional abuse, being physically hurt by a partner, or being forced to have sexual activities.)
Yes
No
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Is there a child 32 months or younger in the home?
Yes
No
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Does the caregiver spend more than 20 hours a week with the child with at least one day 12 hours or more?
Yes
No
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Can the caregiver attend a weekly 2-hour session? (Virtually or in person)
Yes
No
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Do you have a computer or smartphone access?
Yes
No
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Do you have regular internet access?
Yes
No
The SMART Center is a part of the Interprofessional Community Health Clinic. The ICHC is a collaboration among Applied Behavior Analysis (Autism), Counseling, Education Psychology, and Research (CEPR), the School of Social Work which houses the Center for the Advancement of Youth Development (CAYD) and the SMART Center, the Memphis Speech and Hearing Center, and the School of Public Health.
These groups are committed to building a team that reaches across disciplines to serve the community, enhance physical and mental health, and increase scholarship and research. They provide services that may be helpful to you and your family. We can share your contact information with our partners to give you an opportunity to receive more information.
Prior to the release of any personally identifying information to the partners in the ICHC network, we must receive consent from you allowing us to disclose information relevant to assisting you. Please indicate whether you consent to sharing your contact information with our partners:
I consent to sharing my contact information with the ICHC partners
I do not consent to sharing my contact information
We can also provide some academic guidance if you need support for your children. We have access to many resources that have been used to work through some issues some children may have. Would you like to receive information on the services we offer?
Yes
No
We use an assessment tool called the Life Area Needs Survey or LAS. The LAS helps us identify areas where support may be needed. We can provide linkages to services that promote, empower, and nurture families toward economic self-sufficiency and family stability. It can take up to 20 minutes to complete. Would you like to complete it today or at another time? We will call to schedule a suitable time for you.
Yes
No
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