Assessment Form
Secure your place on Our waitlist
Client's Name
*
First Name
Last Name
Client's Phone Number
*
Format: (000) 000-0000.
E-mail
Do we have permission to text/leave a message on the number provide?
*
Yes
No
Client's Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Race
African American
American Indian/Native American
Asian
Caucasian
Hispanic
Islander
Representative's Name (If applicable)
First Name
Last Name
Rep's Organization (Ex: VA, United Way, etc)
Client's Current Living Situation?
*
Incarcerated
Hospital/Facility
Shared Housing/Group Home
Living in a car
Living w/ a friend
Living in a Shelter
Living on the Streets
Other
What type of room does the client prefer?
Shared
Private
No preference
When does the client need to move in?
*
-
Month
-
Day
Year
How long are seeking Housing
*
Short-Term (1-3 Months)
Mid-Term (3-6 Months)
Long-Term (6 Months or more)
Preferred Payment Option(s)?
*
SSI/SSDI
Retirement
Voucher
Organization Funding
Job
Other
Please indicate client's total monthly income. If Client do not receive any, enter "NONE."
*
Does the client suffer from mental illness?
*
Yes
No
If yes, please specify diagnoses
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
Have you been convicted as a Sex Offender? (Your response will not affect your eligibility for our program)
*
Yes
No
With 1000ft restriction
Without 1000ft restriction
Are you currently on Probation or Parole?
*
Yes
No
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?
*
Yes
No
How did you hear about us
*
Search Engine/Web
Social Media
Referral
Other
If referred, please provide the name of the person who referred you?
Submit
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