Supportive Housing Intake Form
Please fill out this form to help us understand your needs and provide appropriate housing support.
Clients Full Name
*
First Name
Last Name
Clients Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to text/leave voicemail on the phone number provided?
*
Yes
No
Email
*
example@example.com
Gender
*
Male
Female
Transgender
Race
*
Black/African American
Caucasian
Hispanic
Native American
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Representatives Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Representatives Name
*
First Name
Last Name
Representatives Email
*
example@example.com
Clients Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your current living situation?
*
Living with a friend
Living in a car
Shelter
Homeless
Hospital/Facility
Shared Living
What type of room preferred?
*
Shared
Private
Do you have any disabilities or special needs?
*
Yes
No
If yes, please describe your disabilities
*
Does the client require a Handicap Accessible living environment?
*
Do you have any history of substance abuse?
*
Yes
No
Do you have any mental health conditions?
*
Yes
No
If yes, please provide details?
*
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
Are you currently on probation or parole?
*
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)
*
How much income do you receive monthly? If none please type NONE
*
How will the client pay?
*
SSI/SSDI
Retirement
Voucher
Organizational Funding
Job
Other
Do you have Health Insurance?
*
Yes
No
When does client need to be placed?
*
-
Month
-
Day
Year
Date
Select all services you are requesting.
*
Transportation Assistance
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 do you hear about us?
*
Referral
Search Engine/Web
Social Media
Other
Submit
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