Supportive Housing Intake Assessment
Client Details:
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Do we have permission to text or call phone number provided?
*
Yes
No
Representatives Name
*
Representative's Email
example@example.com
Representative's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Representatives Organization (United Way, VA etc.)
*
Gender (This is relevant for placement options as some of our homes are separated by gender for to better support resident needs)
*
Male
Female
Transgender
Non-Binary
Race
*
Caucasian
African-American
Hispanic
Asian
American Indian/Native American
Pacific Islander
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Clients current living situation
*
Living with a friend
Living in a car
Living in shelter
Living in the streets/community
Incarcerated
Hospital/Facility
Shared Housing/Group Home
What type of room does client refer
*
Shared room
Private room
What date does client need to be placed
*
-
Month
-
Day
Year
Date
How will client pay
*
SSI/SSDI
Retirement
Voucher
Organization Funding
Job
Other
How much income do you receive monthly? If none please type NONE
*
Does the client suffer from mental illness?
*
Yes
No
If Yes, please list diagnoses
*
Are you disabled?
*
Yes
No
Description of disability/ies
*
Does the 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 answer to this questions does not disqualify you from our program & services)
*
Yes
No
With 1000ft restriction
Without a 1000ft restriction
Are you currently on probation or parole?
*
Yes
No
Will the client have children living with them? (please list ages)
*
Select all the services you are requesting.
*
Transportation Assistance
Job Placement
Apply for SNAP benefits
Apply for SSI/SSDI
Organizational Payee
Health Insurance Enrollment
Clothing Donation
Cellphone/Tablet Assistance
Group Therapy
Day Program
Life Skills/Recovery Group
Submit
Should be Empty: