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Client Assessment Form

Personal Information (* fields required)
Name: (*)
Please type your name in the box above
Type of Sickle Cell Disease: (*)
Please type the type of sickle cell disease you have in the box above.
Name of Parent/Guardian, if applicable:
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Street Address: (*)
Please type your street address in the box above
City, State and ZIP: (*)
Please type your City, State, and Zip in the box above
Parish: (*)
Please type your Parish in the box above.
Primary Telephone (*)
Please type your primary phone number in the box above.
Secondary Telephone
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Email: (*)
Please type your email address in the box above.
Date of Birth: (*)
Please type your date of birth in the box above.
Social Security Number: (*)
Please type your social security number in the box above.
Marital Status: (*)
Please choose an option above.
Race: (*)
Please choose on option above.
Gender: (*)
Please choose an option above.
If client is a student, indicate school:
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Financial Information (* fields required)
Total employment income ($): (*)
Please type your total employment income in the box above.
Other family income ($):
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Total household income ($): (*)
Please type your total household income in the box above
Do you receive any of the following:
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Total benefits income ($):
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Number of persons living in household: (*)
Please type in the total number of persons living in household in the box above.
Does family receive food stamps: (*)
Please choose an option above.
If yes, please give the amount received ($):
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Medical Information (* fields required)
Medicaid Number:
Please type in your medicaid number.
Medicare Number:
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Other Medical Insurance: (*)
Please choose an option above.
Name of Insurance Company:
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Insurance Policy Number:
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Number of persons living
in household with sickle cell trait: (*)
Please type in the number of people in household with sickle cell in the box above.
Number of persons living
in household with sickle cell disease: (*)
Please type in the number of persons in household with sickle cell disease.
List Family Members:
including name, age, gender, disease/trait (*)
Please list the family members including name, age, gender, disease/trait in the box above.
Doctor’s Name: (*)
Please type your doctor's name in the box above.
Hospital currently used: (*)
Please type the name of your current hospital in the box above.
List current medications: (*)
Please list your current medications in the box above.

Service Information (* fields required)
Member of support group? (*)
Please choose an option above.
Attend meetings? (*)
Please choose an option above.
Name of support group:
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What services will you require? (*)
Please list the services you require in the box above.