Intake Form

Set Free Alaska Intake Form

Instructions: The Client Intake Form is to be completed prior to the initial assessment. Completion of this form is required. Please check the boxes, or fill in the blanks below for each question. You must complete all required fields in order to move on. Once completed, you will be instructed on how to proceed.

Step 1 of 4

25%

Client Profile
Name*
FirstLast
Client Gender*
- Male
- Female
If female, maiden name required.*
Mailing Address*
Street AddressCity

StateZIP Code
Email
Enter EmailConfirm Email
Main Contact Phone*
Other Phone
Date of Birth*

MM

DD

YYYY
Social Security Number
SACC Client Id Number (if known)

Payment for Assessment – Set Free Alaska

Please choose the appropriate fee and make your payment for your assessment now. Fees for Assessments are on a sliding scale basis. The Assessment criteria for payment is defined above.
Assessment Fee*
- No Commercial Insurance – Household Income Less Than $25K
- No Commercial Insurance – Household Income $25 – $50K
- Have Commercial Insurance, or income over $50K
Total
$0.00
Email

This field is for validation purposes and should be left unchanged.

Complete this form and follow the payment instructions on the final page. Thank You

Set Free Alaska Intake Form

Step 1 of 4

Client Profile

Demographics

Intake Information

Payment for Assessment – Set Free Alaska