Coordinated Access - HIFIS Intake Form

Client Information

Please enter verifying information about the client you are submitting an intake for.

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* 1. Client first name

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* 2. Client middle name(s), if applicable.

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* 3. Client last name

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* 4. Client HIFIS ID (if known)

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* 5. Client nicknames/alias (if applicable)

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* 6. If you know the client's date of birth, please enter it here.

Client DOB:

Date

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* 7. If you do not know the client's date of birth, please enter an approximate age here.