New Customer Registration Form

Assessment Form

Secure your place on Our waitlist
Client's Name*

First NameLast Name
Client's Phone Number*
E-mail
Do we have permission to text/leave a message on the number provide?*

YesNo
Client's Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Race

African AmericanAmerican Indian/Native AmericanAsianCaucasianHispanicIslander
Representative's Name (If applicable)

First NameLast Name
Rep's Organization (Ex: VA, United Way, etc)
Client's Current Living Situation?*

IncarceratedHospital/FacilityShared Housing/Group HomeLiving in a carLiving w/ a friendLiving in a ShelterLiving on the StreetsOther
What type of room does the client prefer?

SharedPrivateNo preference
When does the client need to move in?*

MonthDayYear
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/SSDIRetirementVoucherOrganization FundingJobOther
Please indicate client's total monthly income. If Client do not receive any, enter "NONE."*
Does the client suffer from mental illness?*

YesNo
If yes, please specify diagnoses
Are you disabled?*

YesNo
List disability(s)
Does client require a Handicap Accessible living environment?*

YesNo
Is the client an ex-offender?*

YesNo
Have you been convicted as a Sex Offender? (Your response will not affect your eligibility for our program)*

YesNoWith 1000ft restrictionWithout 1000ft restriction
Are you currently on Probation or Parole?*

YesNo
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?*

YesNo
How did you hear about us*

Search Engine/WebSocial MediaReferralOther
If referred, please provide the name of the person who referred you?
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Assessment Form