Supportive Housing Intake Assessment

Supportive Housing Intake Assessment

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Email*
example@example.com
Client's Gender*

MaleFemaleTransgender
Client's Name*

First NameLast Name
Representatives Name*

First NameLast Name
Rep's Organization. (ex: VA, Referral, etc.)*
Client's Phone Number*
Please enter Valid Phone. Number
Do we Have permission to text/leave a message on the phone number provided?*

YesNo
Race*

CaucasianAfrican AmericanHispanicAsianAmerican Indian/Native AmericanIslanderOther
Date of Birth*

MonthDayYear
Date
Current Living Situation*

Living w/ a FriendLiving in a carLiving in a shelterLiving on the streetIncarceratedHospital/FacilityShared Housing/Group Home
What type of room does the client prefer?*

SharedPrivate
When does the client need to be placed?*

MonthDayYear
Date
How will the client pay for housing?*

SSI/SSDIRetirementVoucherOrganization FundingJobOther
How much income do you receive monthly? *
If none please type NONE
Does the client suffer from mental illness?*

YesNo
If answered yes, please list mental diagnoses*
If none please type NONE
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?*

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
Will the client have children living with them? (Please list ages)

YesNo
Please select all of the services client will be requesting assistance.*

Apply for Snap benefitsApply for SSI/SSDIOrganizational PayeeClothing DonationCellphone/ Tablet AssistanceDay ProgramHealth Insurance EnrollmentJob PlacementTransportation AssistanceLife Skills/ Recovery Groups
How did you hear about us?*

ReferralSearch Engine/WebSocial MediaWord of mouth
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