Supportive Housing Intake Assessment
Join Our Waitlist
Email
*
example@example.com
Client's Gender
*
Male
Female
Transgender
Client's Name
*
First Name
Last Name
Representative's Name
*
First Name
Last Name
Rep's Organization (ex: United Way, VA, etc)
*
Client's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to text/leave a message on the number provided?
*
Yes
No
Race
*
Caucasian
African American
Hispanic
Asian
American Indian/Native American
Islander
Date of Birth
*
-
Month
-
Day
Year
Date
Client's Current Living Situation
*
Living w/ a friend
Living in a car
Living in a shelter
Living on the street
Incarcerated
Hospital/Facility
Shared Housing/Group Home
What type of room does the client prefer
*
Shared
Private
When does client need to be placed?
*
-
Month
-
Day
Year
Date
How will the client pay?
*
SSI/SSDI
Retirement
Voucher
Organization Funding
Job
Other
How much income do you receive monthly? If none please type NONE
*
Does the client suffer from mental illness?
*
yes
no
If answered yes, list mental diagnoses
*
Are you disabled?
*
Yes
No
List disability(s)
*
Does client require a Handicap Accessible living environment?
*
Yes
No
Is the client an ex-offender?
*
Yes
No
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)
*
Yes
No
With 1000ft restriction
Without 1000ft restriction
Are you currently on Probation or Parole?
*
Yes
No
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?
*
Yes
No
Will the client have children living with them? (Please list ages)
*
Select all of the services you are requesting.
*
Transportation Assistance
Job Placement
Apply for SNAP benefits
Apply for SSI/SSDI
Organizational Payee
Health Insurance Enrollment
Clothing Donation
Cellphone/Tablet Assistance
Group Therapy
Day Program
Life Skills/Recovery Groups
How did you hear about us
*
Referral
Search Engine/Web
Social Media
Word of Mouth
Submit
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