Multi Assistance
Resource Centers Inc.

Client Intake Form

Generous donors and grants are covering the majority of the costs of the program you are about to attend, and we are required to report to them on the participation and outcomes resulting from this program. In order to receive this free or low-cost programming, they require that each participant fill out the entire attached form. All of this information will be kept confidential and will not be used to identify you in any way. We will only need to contact you if the form is not completed in its entirety.

Contact Information

Personal Information

Spouse/Partner's Information


Emergency Contact

Household Information

Gaming Information

Consent for Release of Information