Consumer Information

Name:_____________________

DOB: _____________________ Social Security Number:_____________________

Address:_______________________________________________________________

City: _____________________ County:_____________________ Zip:_____________________

Phone:_____________________ Message Phone:_____________________

E-Mail:_____________________ Gender: Male Female

Functional Disability (Check Primary Category)
Physical
Hearing
Vision
Mental/Emotional
Mental Retardation/Developmental
Learning Disability
Other:_____________________

Primary Diagnosis:_____________________

Secondary Diagnosis:_____________________

Preferred Language:_____________________

Is an Interpreter Needed? Yes No

Race/Ethnicity: (Check all that apply)
Caucasian African American
American Indian or Alaskan Native Hispanic or Latino
Asian Pacific Islander
Other:_____________________

Referred By:
Self
Organization
Family Member/Friend
Other:_____________________
_____________________

Office Use Only
Date Record Opened:_____________________ Date of Revision:_____________________

2700 NE Andresen Rd, Suite d5, Vancouver, WA 98661