CLASS Client Intake Form
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CLIENT INTAKE FORM
First Name
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Last Name
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Legal Rep/Guardian
Primary Email
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Primary Phone
Full Address
Medicaid Number
Birthday
Location
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Austin
Beaumont
Houston
Valley
IPC Effective Date
IPC Expiration Date
Level of Need
Assigned Service Coordinator
Service Coordinator Contact Number
Current Waiver Services
Client's Waiver Program
DSA Contact Number
DSA Address
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