Pathway to Salvation, LLC Housing Intake Form
Please fill out this form to help us understand your needs
Client Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Client's Current Address (If Homeless, enter n/a)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Phone Number
Please enter a valid phone number.
Client’s Email Address
example@example.com
Case Manager/Representative/Payee Name
*
First Name
Last Name
Case Manager/Representative Phone Number
*
Please enter a valid phone number.
Case Manager/Representative Email Address
*
example@example.com
Emergency Contact
First Name
Last Name
Emergency Phone Number
Please enter a valid phone number.
Emergency Contact
First Name
Last Name
Emergency Phone Number
Please enter a valid phone number.
Current Living Situation
*
Living in a car
Shelter
Homeless
Hospital
Jail/Prison
Shared Housing
Living with family/friends
Other
If other, please explain:
Do you have any mental health conditions?
*
Yes
No
If yes, please provide details:
Do you have any disabilities or special needs?
*
Yes
No
If yes, please describe your disabilities or special needs:
Do you have any health conditions?
*
Yes
No
If yes, please explain:
Do you have any history of substance abuse?
*
Yes
No
If yes, when was the last time you used? What is your substance of choice?
Have you ever been convicted as a sex offender?
*
Yes
No
If yes, please explain:
Are you currently on probation or parole?
*
Yes
No
Current Income Source
*
Please Select
SSI
SSDI
Veterans Benefits (VA)
Retirement
Private Pay
Organizational Funding
Monthly Income Amount
*
Do you receive Cal-Fresh (Food Stamps)?
*
Yes
No
Do you have health insurance?
*
Yes
No
When does the client need to be placed in housing?
-
Month
-
Day
Year
Date
How did you hear about us?
*
Referral
Search Engine (Google)
Social Media (Facebook, Instagram, TikTok)
Other
If referred, please enter their name:
Please feel free to add any additional comments below:
Submit
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