Orion ISO CFSS Consultation Service Intake Questionnaire for New Clients

Orion ISO Consultation Service Intake Questionnaire for New Clients

For questions, please contact Orion ISO at 763-299-6676 (option 3) or consultation@orionassoc.net
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Orion ISO Consultation Service Intake Questionnaire for New Clients

For questions, please contact Orion ISO at 763-299-6676 (option 3) or consultation@orionassoc.net
IMPORTANT NOTICE:

By completing this intake questionnaire, you are confirming that you have notified your county’s Lead Agency, Case Manager, or Care Coordinator of your choice to select Orion ISO as your CFSS Consultation Provider.

To proceed with Consultation Services and onboarding to CFSS, a service authorization from your county is required.

If you have not yet informed your county contact (Case Manager, Care Coordinator, or Assessor), please stop and do so now. Once your service authorization is in place, you may return to this form to continue onboarding for consultations services.
Date Notified County*

MonthDayYear
Date

Orion ISO Consultation Service Intake Questionnaire for New Clients

For questions, please contact Orion ISO at 763-299-6676 (option 3) or consultation@orionassoc.net
This questionnaire aims to better understand you or your CFSS participant in order to deliver optimal consultation services. Please complete the form with as much detail as possible.
Requester Information
Who is completing this form?*

Consultation SpecialistResponsible PartyParticipantOther
Today's Date*

MonthDayYear
Date
Participant Information
Participant Legal Name*

First NameLast Name
Participant Email Address
example@example.com
Participant Phone Number
Please enter a valid phone number.
Participant PMI or MA #*
Participant Date of Birth*

MonthDayYear
Date
Participant Date of Assessment*

MonthDayYear
Date
Is the person served overseeing their own services?*

YesNo
HIDE - Is the person served overseeing their own services?*

YesNo
Participant or Participants Representative's Preferred Contact Method*

EmailPhone CallOther
HIDE - Participant or Participants Representative's Preferred Contact Method*

EmailPhone CallOther
Participant Address

Street Address

Apartment or Unit Number

CityState

Zip Code
Participant County of Residence*
HIDE-Participant County of Residence*
Assessments are conducted by Lead Agency county representatives. If you don’t know the date of your assessment, reach out to your county contact.
Participant's Tentative CFSS Start Date*

MonthDayYear
Date
Important Information: If you are new to services, your CFSS start date is tentative and depends on county approval. If you are transitioning from an existing program (PCA or CSG), your CFSS start date will be based on the date of your individual assessment.
Responsible Party Information
Responsible Party Legal Name*

First NameLast Name
Responsible Party Phone Number*
Please enter a valid phone number.
Responsible Party Email Address*
example@example.com
Responsible Party Address*

Street Address

Apartment or Unit Number

CityState

Zip Code
County Representative Information
County Representative Legal Name

First NameLast Name
County Representative Phone Number
Please enter a valid phone number.
County Representative Email Address*
example@example.com
County Representative Agency Name*
Additional Information
Participant Follow-Up Contact Availability- Option 1

MonthDayYear
Date
Hour MinutesAM/PM Option
Participant Follow-Up Contact Availability- Option 2

MonthDayYear
Date
Hour MinutesAM/PM Option
Participant Follow-Up Contact Availability- Option 3

MonthDayYear
Date
Hour MinutesAM/PM Option
Please indicate specific questions regarding CFSS consultation services
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
DISCLOSURE STATEMENT:

By completing and signing this form, you consent to using Orion ISO as your CFSS Consultation Service Provider. You also confirm that you have completed a qualified assessment with your County authorizing CFSS services and have notified your County, Case Manager, or Care Coordinator that have chosen Orion ISO as your CFSS Consultation Provider. Your CFSS start date is contingent upon County approval and, if applicable, the date of your individual assessment.
Signature*

Clear
Date Signed*

MonthDayYear
Date
Please verify that you are human
Should be Empty:

Orion ISO Consultation Service Intake Questionnaire for New Clients

Orion ISO Consultation Service Intake Questionnaire for New Clients

Orion ISO Consultation Service Intake Questionnaire for New Clients

Requester Information

Participant Information

Responsible Party Information

County Representative Information

Additional Information

Signatures