Supportive Housing Intake Form

Supportive Housing Intake Form

Please fill out this form to help us understand your needs and provide appropriate housing support.
Clients Full Name*

First NameLast Name
Clients Phone Number*
Please enter a valid phone number.
Do we have permission to text/leave voicemail on the phone number provided?*

YesNo
Email*
example@example.com
Gender*

MaleFemaleTransgender
Race*

Black/African AmericanCaucasianHispanicNative AmericanOther
Date of Birth*

MonthDayYear
Date
Representatives Phone Number*
Please enter a valid phone number.
Representatives Name*

First NameLast Name
Representatives Email*
example@example.com
Clients Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
What is your current living situation?*

Living with a friendLiving in a carShelterHomelessHospital/FacilityShared Living
What type of room preferred?*

SharedPrivate
Do you have any disabilities or special needs?*

YesNo
If yes, please describe your disabilities *
Does the client require a Handicap Accessible living environment?*
Do you have any history of substance abuse?*

YesNo
Do you have any mental health conditions?*

YesNo
If yes, please provide details?*
Is the client an ex-offender?*

YesNo
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)*

YesNoWith 1000ft restrictionWithout 1000ft restriction
Are you currently on probation or parole?*

YesNo
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?*

YesNo
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/SSDIRetirementVoucherOrganizational FundingJobOther
Do you have Health Insurance?*

YesNo
When does client need to be placed?*

MonthDayYear
Date
Select all services you are requesting.*

Transportation AssistanceJob PlacementApply for SNAP benefitsApply for SSI/SSDIOrganizational PayeeHealth Insurance EnrollmentClothing DonationCellphone/Tablet AssistanceGroup TherapyDay ProgramLife Skills/Recovery Groups
How do you hear about us?*

ReferralSearch Engine/WebSocial MediaOther
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