Supportive Housing Intake Assessment
Join Our Waitlist
Email
*
example@example.com
Client's Gender
*
Male
Female
Transgender
Client's Name
*
First Name
Last Name
Representatives Name
*
First Name
Last 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?
*
Yes
No
Race
*
Caucasian
African American
Hispanic
Asian
American Indian/Native American
Islander
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Current Living Situation
*
Living w/ a Friend
Living in a car
Living in a shelter
Living on the street
Incarcerated
Hospital/Facility
Shared Housing/Group Home
What type of room does the client prefer?
*
Shared
Private
When does the client need to be placed?
*
-
Month
-
Day
Year
Date
How will the client pay for housing?
*
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 answered yes, please list mental diagnoses
*
If none please type NONE
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?
*
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
Will the client have children living with them? (Please list ages)
Yes
No
Please select all of the services client will be requesting assistance.
*
Apply for Snap benefits
Apply for SSI/SSDI
Organizational Payee
Clothing Donation
Cellphone/ Tablet Assistance
Day Program
Health Insurance Enrollment
Job Placement
Transportation Assistance
Life Skills/ Recovery Groups
How did you hear about us?
*
Referral
Search Engine/Web
Social Media
Word of mouth
Submit
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