{{'Intake Form' | translate}}

{{::intake.MemberName}}

This is a form preview only. Any information entered will NOT be saved. To fill out a form for a client, use their timeline from the client’s profile.

{{'This form was submitted on' | translate}} {{intake.Questionnaire.CompletedDate | date:'longDate'}} {{'and can no longer be changed' | translate }}.
{{'This form will be filled out by hand.' | translate}}

{{'Note' | translate}}

{{"Fill out this questionnaire at your own convenience. Your answers are saved as you go, so you don't need to finish it all in one sitting. Submit the form only when you have answered all that you can." | translate}}

{{"Instructions from" | translate}} {{::intake.ClinicName}}

{{::intake.Questionnaire.Instructions}}

{{::question.Text}}

{{question.number}} 

 {{::question.Text}} *

*
* {{'Required' | translate}}
{{'Comment from' | translate}} {{::question.relevantComment.UserName}}:
 {{::question.relevantComment.Text}}


{{"Could not connect to the server. Please make sure your internet connection is working or try again in a minute." | translate}}