Pathway to Salvation, LLC

Pathway to Salvation, LLC Housing Intake Form

Please fill out this form to help us understand your needs
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Client's Current Address (If Homeless, enter n/a)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client’s Email Address
example@example.com
Case Manager/Representative/Payee Name

First NameLast Name
Case Manager/Representative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Case Manager/Representative Email Address
example@example.com
Emergency Contact

First NameLast Name
Emergency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact

First NameLast Name
Emergency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Living Situation

Other
If other, please explain:
Do you have any mental health conditions?
If yes, please provide details:
Do you have any disabilities or special needs?
If yes, please describe your disabilities or special needs:
Do you have any health conditions?
If yes, please explain:
Do you have any history of substance abuse?
If yes, when was the last time you used? What is your substance of choice?
Have you ever been convicted as a sex offender?
If yes, please explain:
Are you currently on probation or parole?
Current Income Source
Monthly Income Amount
Do you receive Cal-Fresh (Food Stamps)?
Do you have health insurance?
When does the client need to be placed in housing?

MonthDayYear
Date
How did you hear about us?
If referred, please enter their name:
Please feel free to add any additional comments below:
Should be Empty:

Pathway to Salvation, LLC Housing Intake Form