Supportive housing intake assessment
Email
*
example@example.com
Gender
*
Male
Female
Transgender
Clients Name
*
First Name
Last Name
Representative Name
First Name
Last Name
Reps Organization (ex. United Way,VA,Etc)
Clients Phone Number
*
Please enter a valid phone number.
Do we have permission to text/leave a message on the number provided?
*
Race?
*
Caucasian
African American
Hispanic
Asian
American Indian/Native American
Islander
Date Of Birth
*
-
Month
-
Day
Year
Date
Clients Current Living Situation ?(Ex. Homeless, car,Family)
*
What Type Of Room Does Client Prefer ?
*
Private
Shared
When does client need to be placed ?
*
-
Month
-
Day
Year
Date
Clients Pay Type
*
SSI\SSDI
Retirement
Voucher
Organization Funding
Job
Other
How much income do you receive monthly? If none please type NONE
*
Does Client Suffer From Mental Illness
*
If answered yes, list mental diagnoses.
Are you disabled?
*
Yes
No
List disability(s)
Does client require 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 questions does not disqualify you from our program & services)
*
Yes
No
With 1000ft restriction
Without 1000ft restriction
Back
Next
Are you currently on Parole or Probation?
*
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
Job placement
Apply for Snap benefits
Apply for SSI/SSDI
Organizational Payee
Health insurance enrollment
Clothing 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: