Supportive Housing Intake Assessment

Supportive Housing Intake Assessment
Email *
example@example.com
Client's Gender *

MaleFemaleTransgender
Client’s Name *

First NameLast Name
Representative’s Name *

First NameLast Name
Representative’s Organization *
Client’s Phone Number *
Do we have permission to text/leave a message on the number provided? *

YesNo
Race*

CaucasianAfrican AmericanHispanicAsianAmerican Indian/Native AmericanIslander
Client’s Date of Birth *

MonthDayYear
Date
Current Living Situation *

Living with a friendLiving in a carLiving in a shelterLiving on the streetIncarceratedHospital facilityShared housing/group home
What type of room does the client prefer? *

SharedPrivate
When does the client need to be placed? *

MonthDayYear
Date
How will the client pay for housing? *

SSI/SSDIRetirementVoucherOrganization fundingJobOther
How much income do you receive monthly? If none please type NONE*
Does the client suffer from mental illness? *

YesNo
If answered yes, list the mental diagnosis: *
Are you disabled?*

YesNo
If answered Yes, please list disabilities: *
Does the client require a handicap-accessible living environment? *

YesNo
Is the client an ex-offender? *

YesNo
Have you been convicted as a sex offender or convicted of any felonies? (Your answer to this question does not disqualify you from our program and services.) *

YesNoBothWith 1000ft restrictionWithout 1000ft restriction
Are you currently on probation or parole? *

YesNo
Do you need help recovering from opioids or any other drugs or alcohol? *

YesNo
Will the client have any children living with them? *

YesNo
Select all of the resources the client is requesting:*

Transportation assistanceJob placementSNAP benefitsClothing donationCell phone or tablet assistance
How did you hear about us *

ReferralSearch engine/webSocial mediaWord of mouth
Proof of income*

Cancelof
Proof of identification*

Cancelof
Should be Empty: