New Hearts Outreach
Confidential Intake Form
STEP 1 - STEP 2 - STEP 3
The first step in the intake process involves you filling out this confidential intake form. Required fields are marked with an asterisk. Please fill out all other fields as you are comfortable. The next step will be scheduling a 30-minute, confidential, intake interview. Someone from our staff will be in touch with you within 2 business days to arrange scheduling.
*Please Check All That Apply: Male Client Female Client Pastor Counselor Parent
*Name: *Last *First MI
*Address: *Street Address Line 1
Street Address Line 2
*City: *State: *Zip Code:
*Phone No. (Please list at least one phone no.)
*Emergency Contact Info: *Name *Relationship
*Phone No. Ext.
*How would you prefer us to contact you? Home Phone Cell Phone Work Phone Email
*When is the best time to reach you? Morning Afternoon Evening Anytime
Please identify what day(s) and time(s) you prefer to schedule a 30-minute, confidential, intake interview. We will
try our best to accommodate you.
*Would you like to receive our newsletters and other publications via mail and/or email? Yes No
Please briefly describe the reason you are contacting New Hearts Outreach.
How would you describe your relationship with the Lord?
Please inform us of anything else you would like to make us aware of.