Shared Housing Intake Assessment
Email
*
example@example.com
Client's Gender
*
Male
Female
Transgender
Client’s Name
*
First Name
Last Name
Representative’s Name (if applicable)
First Name
Last Name
Representative’s Organization (if applicable)
Client’s Phone Number
*
Representative Phone Number
Do we have permission to text/leave a message on the number provided?
*
Yes
No
Race
*
Caucasian
African American
Hispanic
Asian
American Indian/Native American
Other
Client’s Date of Birth
*
-
Month
-
Day
Year
Date
Client’s Current Age
*
Current Living Situation
*
Living with a friend
Living in a shelter
Incarcerated
Reentry
Hospital facility
Group home
Other
What type of room is preferred?
*
Shared
Private
When is placement needed?
*
-
Month
-
Day
Year
Date
In which area does the client prefer to reside? Please specify city, county, or general location preference, if applicable.
How will the client pay for housing?
*
SSI/SSDI
Retirement
Organization funding
Job
Self-pay
Other
How much income do you receive monthly? If none please type NONE
*
Is client ok with shared housing with other individuals?
*
Yes
No
Is client self sufficient?
*
Yes
No
Does the client suffer from mental illness?
*
Yes
No
If answered yes, list the mental diagnosis:
*
Are you disabled?
*
Yes
No
If answered Yes, please list disabilities:
*
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 or convicted of any felonies? (Your answer to this question does not disqualify you from our program and services.)
*
Yes
No
Both
With 1000ft restriction
Without 1000ft restriction
We consider applications from registered sex offenders on a case-by-case basis. To help us complete a thorough assessment, please provide details about your conviction, including the nature of the offense, the date it occurred, any treatment or rehabilitation programs completed, and any other information you believe would help us understand your current circumstances.This information will remain confidential and is used solely to determine eligibility for our housing program, with the goal of ensuring a safe and supportive environment for all residents:
*
Are you currently on probation or parole?
*
Yes
No
Do you need help recovering from opioids or any other drugs or alcohol?
*
Yes
No
Will the client have any children living with them?
*
Yes
No
Select all of the resources the client is requesting:
*
Transportation assistance
SNAP benefits
Clothing donation
Other
How did you hear about us
*
Referral
Search engine/web
Social media
Word of mouth
Proof of income
*
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Proof of identification
*
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