Intake Assessment Form
Join Our Waitlist
Email
*
example@example.com
Client's Name
*
First Name
Last Name
Client's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to text/leave a message on the number provided?
*
Yes
No
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Representative's Name (if applicable)
First Name
Last Name
Rep's Organization (ex: United Way, VA, etc.)
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Client's Gender
*
Please Select
Male
Female
Transgender
Race
*
Caucasian
African American
Hispanic
Asian
American Indian/Native American
Islander
More Than One Race
Client's Current Living Situation
*
Living w/ a Friend/Relative
Living in a car
Living in a shelter
Living on the street
Hospital/Facility
Group Home/Shared Housing
Incarcerated
Type of room client prefers?
*
Shared
Private
When does client need to be placed?
*
-
Month
-
Day
Year
Date
How will the client pay?
*
Social Security
SSI/SSDI
Retirement
Voucher
Organization Funding
Job
Other
Monthly Income (If none please type NONE)
*
Does the client suffer from mental illness?
*
Yes
No
If answered yes, please list mental diagnosis
*
Are you disabled?
*
Yes
No
List disability(s)
*
Does client require a Handicap Accessible living environment?
*
Yes
No
Is the client an ex-offender?
*
Yes
No
Are you currently on Parole or Probation?
*
Yes
No
Do you need assistance recovering from Opioids and/or other drugs and alcohol?
*
Yes
No
Select any requested services you may need.
Apply for SNAP Benefits
Apply for SSI/SSDI
Job Placement
Health Insurance enrollment
Organizational Payee
Transportation Assistance
Cell Phone Assistance
Clothing Donation
Group Therapy
Day Program
Life Skills/Recovery Group
How did you hear about us?
*
Referral
Search engine/Web
Social Media
Word of Mouth
Please verify that you are human
*
Submit
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