Supportive Housing Intake Assessment
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Client's Full Name
*
First Name
Date of Birth
*
First Name
Email
*
Client's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Gender
*
Male
Female
Representative's Name
*
Representative's Organization
*
Race
*
African american
Caucasian
Hispanic/Latino
Asian
American Indian/Native American
Islander
Client's Current Living Situtaion
*
Living with a friend
Living in a shelter
Living in a car
Living on the street
Hospital/Facility
Shared Housing/Group Home
Incarcerated/Halfway House
What type of room does client prefer
*
Private
Shared
What date does client need to be housed by
How will client pay?
*
Employment
SSI/SSDI
Retirement
Family Support
Organization Funding
Other
How much income do you receive monthly?
*
Does the client sufffer from mental illness?
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Yes
No
If answered yes, list mental diagnosis
*
Are you disabled?
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Yes
No
List disability(s)
*
Does client require a Handicap Accessible living environment?
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Yes
No
Is client an ex-offender?
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Yes
No
Has client been convicted/registered as a Sex Offender? *Your answer does not disqualify you from our program or services
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Yes
No
With 1000ft Restriction
Without 1000ft Restriction
Are you currently on Probation or Parole?
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Yes
No
Do you need help with recovering from Opioids and or any other drugs and alcohol?
*
Yes
No
Select all of the services that you are in need of.
*
Job Placement
Apply for SNAP benefits
Apply for SSI/SSDI
Organizational Payee
Health Insurance Enrollment
Cell phone assistance
Therapy
Day Program
Life Skills/Recovery
How did you hear about us.
*
Referral
Search Engine/Web
Social Media
Word of Mouth
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