Step 1 of 8

About You

Your First Name *

Required

Your Last Name *

Required

Street Address *

Required

City *

Required

State *

Required

Zip Code *

Required

Your Date of Birth *

Required

Your Phone Number *

Required

Your Email Address (for W-2s & pay stubs) *

A valid email address is required

When would you like to start? *

Required

Step 2 of 8

Your Schedule

Which days would you like to attend? *

Please select at least one day

Step 3 of 8

Your Financial Information

This information is needed for direct deposit setup and is kept confidential by our payroll team. It is encrypted before being stored.

Your Social Security Number *

Required

Your Bank Routing Number *

Required

Your Account Number *

Required

Confirm Your Account Number *

Required

Step 4 of 8

Your Emergency Contact

Contact Name *

Required

Contact Phone *

Required

Their Relationship to You

Step 5 of 8

Your Health Information

What medications do you take between 9am–2pm? *

Required

Do you have any allergies? *

Required

Your Preferred Hospital *

Required

Your Dentist

Your Doctor

Any diagnoses or conditions we should know about?

Step 6 of 8

Tell Us More About You

What kinds of things upset you? *

Required

What helps you feel calm or safe? *

Required

What do you enjoy doing?

Anything else you'd like us to know?

Step 7 of 8

Federal Tax Withholding (Form W-4)

Your name, address, and Social Security Number from earlier will be used to complete your IRS Form W-4. Complete the fields below to set up your federal income tax withholding.

Filing Status *

Single or Married filing separately Married filing jointly or Qualifying surviving spouse Head of household

Please select a filing status

Multiple Jobs / Spouse Works

I have multiple jobs OR my spouse also works (Step 2(c))

Step 3 — Claim Dependents (if applicable, otherwise leave blank or 0)

Qualifying children under 17

Other dependents

Step 4(a) — Other income (not from jobs), per year

Step 4(b) — Deductions

Step 4(c) — Extra withholding per paycheck

Electronic signature notice. By typing your name below and submitting this form, you are electronically signing IRS Form W-4 under penalties of perjury. You attest that the information you have provided is true, correct, and complete. This electronic signature has the same legal effect as a handwritten signature under IRS regulations (Treas. Reg. § 31.3402(f)(5)-1(c)).

Type your full legal name as signature *

Required

Date *

Required

Step 8 of 8

Photo & Video Release

Photo, Video, and Media Release

I hereby grant Ellis Michael Healthcare Services ("EMHCS"), its partners, employees, and agents permission to take, use, reproduce, publish, and distribute photographs, video recordings, audio recordings, and other media of me (the "Media") for any lawful purpose, including but not limited to marketing materials, social media, the EMHCS website (emhcs.com), printed promotional materials, internal training, and community engagement.

I understand that my likeness and image may appear in connection with EMHCS programs, events, and services, and that I will not receive compensation for the use of the Media. I waive any right to inspect or approve the finished product or any printed or electronic matter that may be used with the Media. I release EMHCS from any claims arising out of the proper use of the Media.

I understand that I may revoke this release at any time by providing written notice to EMHCS, but that revocation does not apply to Media already published or distributed prior to the date of revocation.

Your Decision *

I GRANT permission as described above I DO NOT grant permission

Please select an option

Type your full legal name as signature *

Required

Date *

Required

Client Intake Form

All Done!

Ellis Michael HCS