Intake Assessment Form
This information helps us better understand your current situation, needs, and preferences so we can connect you with the most appropriate housing and support services. All responses are kept confidential and used solely to determine eligibility and placement options
Name
*
First Name
Last Name
Email
*
example@example.com
Date Of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
*
Male
Female
Transgender
Nonbinary
Prefer Not To Answer
Resident’s Representative
*
First Name
Last Name
Representative’s Organization or Relationship To Resident
*
Current Living Environment
*
Staying With Family/Friends
Homeless/Shelter
In A Hospital/Facility
Living In Personal Vehicle
Incarcerated/Halfway Home
Shared Housing/Group Home
Payment Method For Housing
*
Self Pay
Medicaid/Medicare
Organization Funding
Voucher
SSI/SSDI
Retirement Fund
Family Member
Are You A Veteran?
*
Yes
No
Are You Aging Out Of Foster Care?
*
Yes
No
Were You Recently Released From Prison?
*
Yes
No
Are You A Victim Of Domestic Violence?
*
Yes
No
Are You At Risk Of Homelessness Or Being Displaced?
*
Yes
No
Are You Employed?
*
Yes
No
What Is Your Monthly Income? (Proof Of Income Will Be Verified)
*
Do You Have Any Physical or Mental Health Conditions?
*
Yes
No
Unsure/ I Would Like To Be Evaluated
Are You Currently Receiving Medical Or Behavioral Health Services?
*
Yes
No
Do You Have Any Special Care Need? (Mobility Assistance, Medication Reminders, Disability, etc)
*
Yes
No
What Type Of Housing Are Interested In?
*
Shared/Independent Living
Assisted Living
Personal Care Facility
Rehab Facility For Substance Abuse
Extended Care/SIL (For Young Adults
Any Non Medical Alternative Living (Including Boarding Homes, Lodging Facilities, etc)
Housing Preferences?
*
All Female
One Story Homes Only
Residential Homes Only
Institutional Living (Larger Commercial Facilities)
LGBTQ Friendly Housing
None
Do You Need Assistance With Transportion?
Yes
No
Do You Need Assistance With Food?
Yes
No
Do You Need Assistance With Benefits? If so, check the options below
Medicaid/Medicare
SSI/SSDI
SNAP/TANF
Other
Do You Have Access To Healthcare? Check all that apply
No
I Need A New Provider
I Haven’t Been To My Doctor Due To Hardship
Yes
Are You Interested In Life Skills Training? (Cooking, Financial Literacy, Social Events, etc)
*
Yes
No
Undecided
Do You Need Assistance With Job Placement/Training?
*
Yes
No
Any additional notes or concerns can be added below:
I Consent To The Use Of This Information For Placement And/Or Referral Purposes
*
Yes
Signature of client or their representative
*
Customer data is not shared with third parties for promotional or marketing purposes. Any information sharing that may be mentioned elsewhere in this policy excludes mobile opt-in data.Messaging Terms and Conditions by providing your phone number and agreeing to receive texts, you consent to receive text messages from Quality Of Life Housing Inc., from 833-224-1640 regarding customer care. Consent is not a condition of purchase. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time or HELP for assistance. You can also contact us at 833-224-1640 or Contact@qolhousing.org. Mobile opt-in information is never shared with third parties. Do you accept to opt in?
*
Yes
No
Continue
Continue
Should be Empty: