Co-Living Housing Intake Assessment
Join our Waitlist
Basic Information:
Client's Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
E-mail (if available)
example@example.com
Do we have permission to text/leave a message on the number provided?
*
Yes
No
What city and state are you currently staying in or planning to go to?
Current Living Situation
*
Living with a friend
Living in a car
Living n a shelter
Living on the street
Hospital/Facility
Shared Housing/Group Home
Living alone
Travelling
Are you a Veteran?
Yes
No
Representative's Name (if applicable)
First Name
Last Name
Representative's Organization (ex: United Way, VA, etc.)
How did you hear about us?
*
Please Select
Agency
Case Manager
Family Member
Self
Other
Please Specify
*
Income & Benefits
Does the client have a steady source of income?
*
Yes
No
How will the client pay
*
Employment
SSI/SSDI
VA Benefits
Organization Funding
Employment paycheck
Other
If you selected "Other" as your main source of income, please specify below (please input "N/A" if you did not select Other).
*
How much income does the client receive monthly ?
*
Please upload an image of your proof of income (i.e, paycheck stub, award letter, etc.)
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Independent Living Abilities
Are you able to live independently without daily assistance?
*
Yes
No
Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)?
*
Yes
No
Are you currently taking any prescribed medications?
*
Yes
No
Housing Preferences & Needs
When do you need housing (move-in date)?
*
-
Month
-
Day
Year
Date
What type of room is the client looking for? (select all that apply)
*
Shared Room
Private Room
Private Room with Bathroom
No preference
Please list any physical disabilities or mobility concerns and any required Handicap Accessible in the client's living environment (if none, please input "N/A").
*
Please select the client's preference for the number of floors for the house you are placed in
*
1 floor house
2 floor house
No preference
Has the client been diagnosed with a mental illness?
*
Yes
No
If yes, please list mental health diagnosis (if none, please input "N/A").
*
Is the client currently on probation or parole?
*
Yes
No
Is the client an ex-offender?
*
Yes
No
Additional Information
Please add any additional information that you would like us to know (if none, please input "N/A").
*
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