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Roasted Almonds

Rebirth & Renewal 

Pre-Intake Client Form

Please complete this form so we can better serve you.

Client Pre-Intake

Client Name

Birthday
Month
Day
Year
Multi-line address

Rebirth and Renewal Family Resource Center proudly accepts Medicaid for all services we offer.

What Services is the client interested in?
What is the client's housing situation?
Houseless (living in shelter, place to place, car)
Living with family or friends (Client does not have a current lease to their own name)
Has housing (Client has a lease in their name)
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