Housing Intake Assessment

Housing Intake Assessment

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Email*
example@example.com
Client's Gender*

MalefemaleTransgender
Client's Name:*

First NameLast Name
Representative's Name (Case Manager) If You do not have a Case Manager put your first and Last name*

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

YesNo
Race*

CaucasianAfrican AmericanHispanicAsianAmerican Indian/ Native AmericanIslander
Date Of Birth*

MonthDayYear
Date
Client's Current Living Situation*

Living with a friendLiving in a carLiving in a ShelterLiving on the streetIncarceratedHospital/FacilityShared Housing/Group Home
When does Client need to be placed?*

MonthDayYear
Date
How will the client pay ?*

SSI/SSDIRetirementVoucherOrganization FundingJobOther
How much Income do you receive monthly? If none please type NONE*
Confirm Income*

Cancelof
List any Medications you are currently taking
Does the client suffer from mental illness?*

YesNo
If answered yes, list mental diagnosis . If none, type NONE*
Are you disabled ?

YesNo
List Disability(s) If none , Type NONE*
Does client require a Handicap Accessible Living environment*

YesNo
Is the Client an ex-offender*

YesNo
Have you been convicted as a Sex Offender? (Your answer to this question does not disqualify you from our program & Services)*

YesNoWith 1000ft restrictionWithout 1000ft restriction
Are you currently on Probation or Parole ?*

YesNo
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?*

YesNo
Will the Client have children living with them (Please List ages)*
Select all of the services you are requesting .*

Transportation AssistanceJob PlacementApply for SNAP benefitsApply for SSI/SSDIOrganizational PayeeHealth Insurance EnrollmentClothing DonationCellphone DonationCellphone/Tablet AssistanceGroup TherapyDay ProgramLife Skills/Recovery Groups
How did you hear about us*

ReferralSearch Engine/WebSocial MediaWord Of Mouth
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