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Client Intake For Menands & Watervliet
Client Intake For Menands & Watervliet
Capital District Digital
2023-04-04T10:58:17-04:00
Client Intake For Menands & Watervliet
Where are you a resident?
(Required)
Menands
Watervliet
New or Renew?
(Required)
New
Renew
Today's Date
(Required)
Name
(Required)
First
Middle
Last
Date of Birth (must be 60 or older)
(Required)
MM slash DD slash YYYY
Albany Co Resident?
(Required)
Yes
No
Check the coverages you have.
(Required)
Medicaid
Medicare
Humana
If Medicade, what is your Medicade #:
(Required)
Client Phone #:
Cell Phone #:
(Required)
Address
(Required)
Street Address
City
ZIP / Postal Code
Email:
(Required)
Emergency Contact #1:
(Required)
Name
Phone:
(Required)
Relationship to client:
(Required)
Emergency Contact #2:
(Required)
Name
Phone:
(Required)
Relationship to client:
(Required)
Do you live alone?
(Required)
Yes
No
Are you
(Required)
Single
Married
Widowed
Divorced
Race/Ethnicity:
(Required)
Hispanic or Latino
White/Caucasian
Black
Asian
Hawaiian/Pacific Island
Native American
2 or more Races
Are you disabled or frail?
(Required)
Yes
No
What makes you disabled or frail?
(Required)
Do you use any of the following or no?
(Required)
Walker
Wheelchair
Scooter
Cane
Hearing Impaired
Visually Impaired
None
Are you a Veteran?
(Required)
Yes
No
Do you have access to transportation?
(Required)
Yes
No
How do you currently get around?
(Required)
Does anyone in your household have access to a car?
(Required)
Yes
No
Can you or someone else drive you to some of your appointments? (Explain why and when you will need to use transportation)
(Required)
Do you use the STAR Bus? (If you are eligible for STAR, did you know that STAR does nnot limit the type of rides they provice? Ex. Hair appointments, trips to the mall, etc.)
(Required)
Yes
No
Can we send you an application for the STAR Bus?
(Required)
Yes
No
Application Mailed?
(Required)
Yes
No
Do you live near a bus stop?
(Required)
Yes
No
Closest bus line & bus stop:
Have you ever used the bus for transportation?
(Required)
Yes
No
If you do live near a bus stop, is there any reasons why you don't ride the bus?
(Required)
61027
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