Southern California - Intake Screening Form
Section 1
Client Information
Owner ID Hidden Field
What type of Service are you requesting?
*
Please Select
Emergency Shelter
Rental Assistance
Utility Assistance
Other
If other, please explain:
Full Name
*
First Name
Last Name
Gender
Female
Male
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Email Address
Date Of Birth
*
-
Month
-
Day
Year
Date
Do you have proof of ID?
*
Yes
No
Do you have proof of Social Security Card/Number? (*Required for Eligibility)
*
Yes
No
What is your present living situation? Please explain.
*
What city are you currently located?
*
What are 3 goals you have?
*
Goal 1
Goal 2
*
Goal 3
*
What are 3 challenges standing in your way of reaching your goals?
*
Challenge 1
Challenge 2
*
Challenge 3
*
Would you say you are looking primarily for a place to stay or for a structured program to help you make a change in your life?
*
Please Select
Place to Stay
Program to Change
If you are looking to make a change in your life, what would that change be?
Section 2
Children
Do you have any children in your custody?
*
Yes
No
How many?
How often?
Please Select
Full Time
Part Time
Visitation
Please list their ages and genders:
Do you have proof of Social Security Card/Number for all the children in your custody?
Yes
No
Do you have an open CPS or CFS Case?
*
Yes
No
If yes, where are you at in the process?
If your children are not in your custody, are you interested in reunifying with them?
Yes
No
Do you have court ordered visitation with your children?
Yes
No
Section 3
Substance Abuse/Drug & Alcohol Conditions
When was the last time you used any drugs, alcohol or smoked marijuana?
-
Month
-
Day
Year
Date
Drug of choice?
Are you in any type of recovery program for substance abuse?
*
Yes
No
Please list the name of the last recovery program you attended:
Can you pass a clean urine analysis screening? (Required for eligibility)
*
Yes
No
Section 4
Medical Conditions
Do you have any medical issues?
*
Yes
No
If yes, please explain the medical issues:
Have you been diagnosed with a mental illness?
*
Yes
No
If yes, please explain the mental illness:
Are you taking any prescribed medication?
*
Yes
No
Please list each prescribed medication:
Do you require assistance with the administration of your medications?
*
Yes
No
Do you require any ADA Special Accommodation?
*
Yes
No
If yes, please explain the ADA Special Accommodations:
Section 5
Justice-Involved Matters
Have you ever been incarcerated?
*
Yes
No
Last release date:
How much time have you served?
Are you on Parole/Probation?
*
Yes
No
Do you have any outstanding warrants?
*
Yes
No
Have you ever been a victim/perpetrator of domestic violence?
*
Yes
No
How long ago?
Are you fleeing from an abuser?
*
Please Select
Yes
No
Can you lawfully be around children?
*
Yes
No
Can you emotionally be around children?
*
Yes
No
Do you have court ordered classes?
*
Yes
No
Please explain:
Section 6
Income
Do you have a source of income?
*
Yes
No
List your income type:
*
Income amount:
*
Are you able and willing to work?
*
Please Select
Yes
No
Already have a job
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