A Place of Hope and Peace Housing Intake Assessment
Join Our Waitlist
Client's Email
*
example@example.com
Client's Name
*
First Name
Last Name
Client's Gender
*
Male
Female
Other
Race
*
Caucasian
Black or African American
Hispanic
Asian
American Indian/Native American
Pacific Islander
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Client's Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to text and/or leave a message on the number provided?
*
Yes
No
Representative's Name
*
First Name
Last Name
Rep's Organization (ex: United Way, VA, etc)
*
Representative's Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Current Living Situation
*
Living w/ a friend
Living in a car
Living in a shelter
Living on the street
Hospital/Facility
Shared Housing/Group Home
Client's Emergency Contact
*
First Name
Last Name
Client's Emergency Contact Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
What type of room does the client prefer
*
Shared Room
Private Room
How will the client pay?
*
SSI/SSD
Retirement
Voucher
Organization Funding
Job
Other
How much income does the client receive monthly? If none, please type NONE
*
When does client need to be placed?
*
-
Month
-
Day
Year
Does the client suffer from mental illness?
*
Yes
No
If answered yes, list mental diagnoses
*
Can Client manage medications without assistance.
*
Yes
No
Are you disabled?
*
Yes
No
List disability(s)
*
Can Client manage all daily activities (bathing, dressing, cooking, & cleaning)
*
Yes
No
Does client require Handicap Accessible living environment?
*
Yes
No
Has client been convicted of any Violent Crimes or as a Sex Offender?
*
Yes
No
Do you need help with recovering from drugs and/or alcohol?
*
Yes
No
Select all of the services you are requesting.
Health Insurance Enrollment
Transportation Assistance
Job Readiness assistance
Apply for SNAP benefits
Organization Payee
Apply for SSI/SSDI
Clothing Donation
Group Therapy
Submit
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