VIETNAMESE PRIMARY HEALTH CARE NETWORK PROJECT

CLIENT INTAKE FORM

(Please fax the completed form to Hien Le on 87174030

For confidentiality reason, you must ring 8717 4009 to inform staff before sending a fax)

Surname

Name

Address

Phone No

(W)

(H)

Mobile:

Sex

           Male/ Female

Date of Birth

Age

Country of birth

Language spoken

Interpreter needed

            Yes / No

Relationship status

Employment Status

For children only

Which School:

Has a school counsellor been involved?

                    Yes / No

Relevant Information (Client History)

Referring Agent’s Request/ Plan

Referred to

Referred by

Phone No

Fax No

Doctor’s Signature

Date

Patient’s signature

Date: