Aligned 325 Housing Intake Assessment
Please complete this form accurately to help us assess your housing needs and determine eligibility.
Client's Name
*
First Name
Last Name
Client's Email
*
example@example.com
Client's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to text/leave a message on the number provided?
*
Yes
No
Client's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Birthday
*
-
Month
-
Day
Year
Date
Client's Gender
*
Male
Female
Transgender
Client's race
*
Hispanic
African American
Caucasian
Native American
Asian
Other
Client's Room Preference
*
Private
Shared
Client's Method of Payment
*
SSI/SSDI
Organizational Funding
Retirement
Job
Other
Client's Monthly Income (If None type "NONE")
*
Please Upload A Valid Form Of Identification
*
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of
Proof of Income
*
Browse Files
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Choose a file
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of
Does the client have a history of mental health conditions?
*
Yes
No
If applicable, describe the condition(s) below. Otherwise, type "N/A."
*
Does client have a physical, mental, or developmental disability?
*
Yes
No
If applicable, please describe the disability or condition below. If not, enter "N/A."
*
Does the client need a home with accessibility features (e.g., wheelchair access, grab bars)?
*
Yes
No
Has client ever been convicted of a sex offense? Note: Your response will not automatically disqualify you from our program or services.
*
Yes
No
Presently on probation or parole?
*
Yes
No
Does client require assistance with substance use recovery (including opioids, alcohol, or other drugs)?
*
Yes
No
Will the client have any children living with them?
*
Yes
No
Which of the following resources is the client seeking? (Select all that apply)
*
Transportation
SNAP
Job placement
Cell Phone/Tablet
None
Other
If other, please explain what resources you are in need of. If none, type "N/A"
*
How did you hear about us?
*
Google
Referral
Social Media
Word of mouth
Flyer
Representative's Info (If none type "N/A" in all fields)
*
First Name
Last Name
Representative's Email
*
example@example.com
Representative's Organization
*
Submit
Should be Empty: