Housing Placement Intake

Housing Prescreening
Name

First NameLast Name
Date of Birth

DayMonthYear
Gender
Phone Number
Email
example@example.com
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for needing to move?
Are you currently homeless or at risk of being homeless?

Yes, I am homelessI'm at risk of being homelessNo, I just want my own space
When do you need a bed/room?

MonthDayYear
Date
What is your current living situation?

ShelterCouch SurfingIncarcerated (Re-entry)Hospital/FacilityOther
What type of room are you requesting?
Do you have any disabilities?

YesNo
If yes explain.
Have you ever been convicted of a felony?

YesNo
If yes, explain
Are you a registered sex offenderr?

YesNo
Are you on probation or parole?

YesNo
Do you require case management services?

YesNo
Are you currently working with a case manager or social worker?

YesNo
If yes, Name of Organization and Phone Number.
Do you have a mental diagnosis?

YesNo
If yes, Diagnosis:
Do you take prescribed medications?

YesNo
Are you medication compliant?

YesNo
What is your monthly income amount?*
Employment Status
What source of income do you receive?
Are you able to pay the program fee monthly?

YesNoWith assistance
Do you have support from family or friends?

YesNo
Are you willing to live in a shared environment?

YesNo
Are you able and willing to follow house rules and participate in check-ins?

YesNo
Do you have any substance use issues?

YesNo
Are you actively seeking treatment or in recovery?

YesNo
Any additional information
Should be Empty:

Housing Prescreening