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Intake Tool
Form 1 of 4
For your convenience, this section of the ClientCenter is provided so you can complete your required intake paperwork using a computer or other device.
NOTICE: PHH staff are not permitted to see clients until this paperwork is received, so we ask that you complete and submit this electronic packet at least 48 hours prior to your first appointment.
Instructions
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This entire packet must be completed by, or for, each individule participating in any service provided by PHH.
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If this form is being filled out by an adult for a minor child or a dependent adult under the guardianship of the one filling out the form, the child or dependent adult's name and address are to be used in Section A and your information must be provided in Section B.
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If you are simply assisting a person who cannot complete the form on their own, your information must be provided in Section B.
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Information provided in this and other forms may be used to determine your eligibility for rate reduction using our sliding-scale rate chart and to determine your rate.