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
Address
Medicaid Number
Birthday
Location
Make a selection
Austin
Beaumont
Houston
Valley
IPC Effective Date
IPC Expiration Date
Level of Need
LIDDA Service Coordinator
Service Coordinator Contact Number
Client's Waiver Program
Current Waiver Services
DSA Contact Number
Submit