Intake Application
Our team will follow up within 1-2 business days.
Email
*
example@example.com
Client's Gender
*
Male
female
Transgender
Client's Name:
*
First Name
Last Name
Case Manager Name (If you don't have one type N' No.)
*
First Name
Last Name
Client's 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 with a friend
Living in a car
Living in a Shelter
Living on the street
Incarcerated
Hospital/Facility
Shared Housing/Group Home
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
*
Confirm Income*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have a Mental Illness ?
*
Yes
No
If answered yes, list mental diagnosis . If none, type NONE
*
List any Medications you are currently taking
*
Are you disabled ?
Yes
No
List Disability(s) If none , Type NONE
*
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 question 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 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
Should be Empty: