1. (a) Pursuant to He-M 401, an application for services shall be completed and signed by the individual or guardian at or before the intake interview.

2. (b) The following demographic data shall be collected and documented:

   1. (1) Name, address, and telephone number of the individual or applicant;
   2. (2) Date of application for services;
   3. (3) Date of birth of the individual or applicant;
   4. (4) Name, address, and telephone number of guardian, if applicable;

   5. (5) Financial information including:

      1. a. Insurance;
      2. b. Private resources; and
      3. c. Eligibility determinations for financial assistance from programs such as Supplemental Security Income, Aid to the Permanently and Totally Disabled, Medicare, Medicaid, and food stamps;
   6. (6) Emergency contact information;
   7. (7) Educational history;
   8. (8) Marital or civil union status;
   9. (9) Living situation;
   10. (10) Employment status and history;
   11. (11) Race, ethnicity, and primary language;
   12. (12) Gender;
   13. (13) Gender identification; and

   14. (14) Current legal involvement, such as:

       1. a. Probation or parole;
       2. b. Conditional discharge;
       3. c. Guardianship; and
       4. d. Any other court ordered involvement.
3. (c) Data collected in (b) above shall be reviewed and a hard copy signed by the individual at least annually and updated as needed.

Source. #2039, eff 7-1-82; ss by #2423, eff 7-13-83; rpld by #2468, eff 9-6-83 New. #3051, eff 7-8-85, EXPIRED: 7-8-91 New. #7281, eff 5-23-00, EXPIRED: 5-23-08 New. #9512 eff 7-9-09; ss by #12409, eff 10-24-17