QOL Intake Assessment Form

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 NameLast Name
Email*
example@example.com
Date Of Birth *

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Alternative Contact Number
Please enter a valid phone number.
Gender*

MaleFemaleTransgenderNonbinaryPrefer Not To Answer
Resident’s Representative *

First NameLast Name
Representative’s Organization or Relationship To Resident*
Current Living Environment*

Staying With Family/FriendsHomeless/ShelterIn A Hospital/FacilityLiving In Personal VehicleIncarcerated/Halfway HomeShared Housing/Group Home
Payment Method For Housing*

Self PayMedicaid/MedicareOrganization FundingVoucherSSI/SSDIRetirement FundFamily Member
Are You A Veteran?*

YesNo
Are You Aging Out Of Foster Care?*

YesNo
Were You Recently Released From Prison?*

YesNo
Are You A Victim Of Domestic Violence?*

YesNo
Are You At Risk Of Homelessness Or Being Displaced?*

YesNo
Are You Employed?*

YesNo
What Is Your Monthly Income? (Proof Of Income Will Be Verified)*
Do You Have Any Physical or Mental Health Conditions?*

YesNoUnsure/ I Would Like To Be Evaluated
Are You Currently Receiving Medical Or Behavioral Health Services?*

YesNo
Do You Have Any Special Care Need? (Mobility Assistance, Medication Reminders, Disability, etc)*

YesNo
What Type Of Housing Are Interested In?*

Shared/Independent LivingAssisted LivingPersonal Care FacilityRehab Facility For Substance AbuseExtended Care/SIL (For Young AdultsAny Non Medical Alternative Living (Including Boarding Homes, Lodging Facilities, etc)
Housing Preferences?*

All FemaleOne Story Homes OnlyResidential Homes OnlyInstitutional Living (Larger Commercial Facilities)
Are You Interested In Life Skills Training? (Cooking, Financial Literacy, Social Events, etc)*

YesNoUndecided
Do You Need Assistance With Job Placement/Training?*

YesNo
I Consent To The Use Of This Information For Placement And/Or Referral Purposes*

Yes
Signature*

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