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Intake Form / Legal Acknowledgement

By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message. Message & data rates may apply. Reply STOP to opt out of further messaging.

Phone Type
OK to leave messages?
OK to Text?
How did you hear about us?

Confidential Information

This information is helpful for our anonymous reporting to our funding sources and securing grant monies. 

Marital Status
Gender
Education
Are you in need of permanent housing?
Are you homeless?
What best describes your living situation?
Employment Status

We want to know how many people are impacted by our help, so we want to know how many people are in your household?

Household Income
Race Self-Identification: (Check all that apply):
Ethnicity Self-Identification: (Check all that apply):
Do you or anyone in your family receive?
Do you or anyone in your family receive subsidized:

Confidentiality Policy*

WE CAN is committed to making this a safe space for all of us.

Our policy on confidentiality states that everything participants share with staff and volunteers is confidential unless a participant shares they are going to hurt themselves or someone else, or if a child, elder or disabled person is being abused or neglected.

Within our groups and workshops, participants will keep confidential all that is shared in the meetings. WE CAN staff reserves the right to ask a participant to leave our programming if we have reason to believe that the confidentiality of the group is violated.

Substance Use Policy*

WE CAN requires that a participant be sober and not use alcohol or drugs on the day of a walk in, appointment, workshop or group. This is necessary for WE CAN to provide a safe space for our programming and events and to support women in recovery as well as women who have been impacted by loved ones who have or had a substance use disorder.

If a participant appears intoxicated or under the influence of drugs, WE CAN will ask the participant to leave the group, workshop, appointment etc and arrange a sober ride home (friend, family, taxi) with assistance from WE CAN.  If a participant leaves the premises while driving a vehicle and appearing intoxicated/under the influence of drugs, the WE CAN staff/intern/volunteer must call the police to notify them with the participant’s name and a description of the vehicle. 

WE CAN staff and volunteers reserve the right to call local Rescue at 911 if we have serious concerns about a participant’s health (including intoxication/under the influence of drugs) to ask Rescue to make an assessment.

COVID Policy

WE CAN's COVID policy evolves in response to current local COVID conditions and health guidelines. In general, we encourage mask wearing, but do not require masks. We can provide a mask for anyone who requests one. If you are feeling unwell on the day of your appointment, please call our office and we will arrange for the appointment to be held by phone or videoconference. 

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If you have an in-person appointment and local conditions have changed to the point where we require masks in our office, we will let you know at the time of your confirmation call. Thank you.

Legal Acknowledgements*

  • The attorney I meet with today is a WE CAN volunteer providing this service at no cost to me.

  • The purpose of this consult is to obtain information so I may better advocate for myself.

  • The attorney will meet with me for a limited amount of time and will do his/her best to answer my questions within that time.

  • The attorney has not investigated the facts of my case nor done research specific to my issues and will do his/her best to provide me general advice and information based on the information that I provide today.

  • The attorney does not represent me based on this consult and will not file anything on my behalf, appear in court with me, or otherwise take action on my behalf.

  • Although the consult is confidential, it is not intended to create an “attorney-client” relationship.

  • The attorney I meet with today will not reveal the content of the consult to anyone other than WE CAN staff or another WE CAN volunteer attorney without my permission unless ordered to by a judge.

  • I may choose to hire an attorney to represent me in this matter.

  • It is possible that the attorney I meet with today, an attorney in his/her firm, or another WE CAN volunteer attorney might consult with, advise, or be retained by the other side in my case without my permission and without notice to me.

  • I may request another consult regarding the same issue discussed today if there are substantial changes to my situation, new information comes to my attention, or if my case progresses to a new stage.

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