Supportive Housing Intake and Evaluation Form

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?*

YesNo
Please confirm whether the client will have any children residing in the unit, as our program does not support family placements at this time.*

YesNo
Name of Client*

First NameLast Name
Date of Birth*
Client Email*
example@example.com
Client Phone Number*
Please enter a valid phone number.
What is the client’s preferred date for placement?*

MonthDayYear
Date
Client Gender (please specify)*

MaleFemaleTransgender
Client Race/Ethnicity*

African AmericanCaucasianNative American/American IndianPacific IslanderOther
Is a handicap-accessible living space required for the client?*

YesNo
Is the client managing any diagnosed mental health conditions?*

YesNo
If applicable, please specify the client’s mental health diagnoses.*
Is the client disabled?*

YesNo
If applicable, please specify the client’s disability.*
Is the client currently on Probation or Parole?*

YesNo
We provide an independent, drug- and alcohol-free living environment. Is the client currently seeking support for recovery from opioids, other substances, or alcohol?*

YesNo
Client Living Situation at Time of Assessment?*

Shared Housing or Group HomeLiving in a VehicleLiving with Family or FriendLiving in a ShelterLiving on the StreetIncarceratedHalfway/Transition HousingHospital or Other Structured FacilitySpecify if not listed________________________
Please specify client's monthly income. If applicable, enter "None"*
What is the client’s preferred room type?*

SharedPrivate
Please specify the client’s payment arrangement(s) (select all that apply).*

SSI/SSDIRetirementOrganization FundingJobVoucherOther (please specify)_________________________________
Please specify the services for which the client is requesting assistance with the application process, if applicable*

EmploymentSupplemental 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 *

First NameLast Name
Client Representative Phone Number*
Please enter a valid phone number.
Referring Organization (e.g., United Way, VA, etc.)**
Can we leave a voicemail or send a text message to the phone number you’ve provided?*

YesNo
How were you referred to our program?*

Referral (if applicable, please specify)________________________Word of MouthSearch EngineSocial MediaPublic outreach materials (e.g., Flyers, business cards, poster etc)
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