Supportive Housing Intake and Evaluation Form
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Our program is unable to admit individuals with convictions for murder or sexual offenses. Has the client ever been legally convicted of either of these offenses?
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Yes
No
Please confirm whether the client will have any children residing in the unit, as our program does not support family placements at this time.
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Yes
No
Name of Client
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First Name
Last Name
Date of Birth
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Client Email
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example@example.com
Client Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
What is the client’s preferred date for placement?
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-
Month
-
Day
Year
Date
Client Gender (please specify)
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Male
Female
Transgender
Client Race/Ethnicity
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African American
Caucasian
Native American/American Indian
Pacific Islander
Other
Is a handicap-accessible living space required for the client?
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Yes
No
Is the client managing any diagnosed mental health conditions?
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Yes
No
If applicable, please specify the client’s mental health diagnoses.
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Is the client disabled?
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Yes
No
If applicable, please specify the client’s disability.
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Is the client currently on Probation or Parole?
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Yes
No
We provide an independent, drug- and alcohol-free living environment. Is the client currently seeking support for recovery from opioids, other substances, or alcohol?
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Yes
No
Client Living Situation at Time of Assessment?
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Shared Housing or Group Home
Living in a Vehicle
Living with Family or Friend
Living in a Shelter
Living on the Street
Incarcerated
Halfway/Transition Housing
Hospital or Other Structured Facility
Specify if not listed________________________
Please specify client's monthly income. If applicable, enter "None"
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What is the client’s preferred room type?
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Shared
Private
Please specify the client’s payment arrangement(s) (select all that apply).
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SSI/SSDI
Retirement
Organization Funding
Job
Voucher
Other (please specify)_________________________________
Please specify the services for which the client is requesting assistance with the application process, if applicable
*
Employment
Supplemental Nutrition Assistance Program (SNAP) benefits (GA only)
SSDI (Social Security Disability Insurance) A benefit for individuals who are disabled and have worked and paid Social Security taxes long enough to qualify. It’s based on your work history and earnings, not financial need.
SSI (Supplemental Security Income) A needs-based program that provides monthly payments to individuals who are aged (65+), blind, or disabled and have limited income and resources. It's funded by general tax revenues (not Social Security taxes).
Obtaining an Electrical Device (e.g., Cell Phone and/or Tablet) with SNAP benefits (GA only)
Transportation with SNAP Benefits (GA Only)
N/A
Client Representative
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First Name
Last Name
Client Representative Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Referring Organization (e.g., United Way, VA, etc.)*
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Can we leave a voicemail or send a text message to the phone number you’ve provided?
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Yes
No
How were you referred to our program?
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Referral (if applicable, please specify)________________________
Word of Mouth
Search Engine
Social Media
Public outreach materials (e.g., Flyers, business cards, poster etc)
Submit
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