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San Francisco
Human Services Agency

Intake Form Assistant

Username

Password

San Francisco
Human Services Agency

Intake Form Assistant

J. Smith · Downtown Office

New Intake

Fields prefilled

Data sources

Fields corrected

First Name *

Last Name *

Date of Birth *

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Enter the applicant's name and date of birth above to pull their information and begin the intake.

Personal Information

Prefilled

First Name Source: Medi-Cal

Last Name Source: Medi-Cal

Pronouns Source: Medi-Cal

Date of Birth Source: Medi-Cal

Street Address Source: Medi-Cal

City Source: Medi-Cal

State Source: Medi-Cal

Zip Code Source: Medi-Cal

Phone Number Source: Medi-Cal

Email Address (Optional)

Race, Ethnicity & Identity

Prefilled

Ethnicity Source: Medi-Cal

Language Spoken at Home Source: Medi-Cal

Race (select all that apply)

American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Other Pacific Islander White

Source: Medi-Cal

Gender Identity Source: Medi-Cal

Sexual Orientation Source: Medi-Cal

Family Size, Income & Certification

Prefilled

Family Type Source: Medi-Cal

Family Size Source: Medi-Cal

Estimated Income (next 12 months) Source: Medi-Cal

Income Level Auto-calculated from family size and income

Income Verification Source

Payroll Stub Tax Return Unemployment Benefits Veteran's Benefits Public Benefits (Medi-Cal) Rental Assistance Self-Certified

Applicant Confirmation & Signature

✎ By signing below, I acknowledge the information provided is true and correct and consent to sharing it for workforce services enrollment.

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Sign here

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New Intake

Personal Information

Race, Ethnicity & Identity

Family Size, Income & Certification

Applicant Confirmation & Signature

Intake Submitted