Supportive housing intake assessment
Email
*
example@example.com
Gender
*
Male
Female
Transgender
Client's Name
*
First Name
Last Name
Representatives Name
First Name
Last Name
Reps Organization (ex. United Way, VA, etc.)
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?
*
Date of Birth
*
-
Month
-
Day
Year
Date
Race
*
Caucasian
African American
Hispanic
Asian
American Indian/Native American
Islander
Other
Clients current living situation (Ex. Homeless, car, family,etc.)
*
What type of room does client prefer?
*
Private
Shared
When does client need to be placed?
*
-
Month
-
Day
Year
Date
Clients pay type
*
SSI/SSDI
Retirement
Voucher
Organizational funding
Job
Other
How much income does client receive monthly? If None please type NONE
*
Does client suffer mental illness?
*
If answered yes, list mental diagnosis.
Are you disabled?
*
Yes
No
List disability(s)
Does client require handicap accesible living environment?
*
Yes
No
Is client an ex offender
*
Yes
No
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)
*
Yes
No
Within 1000ft restriction
Without 1000ft restriction
Are you currently on parole or probation?
*
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)
*
Select all of the services you are requesting*
*
Transportation
Job placement
Apply for SNAP benefits
Apply for SSI/SSDI
Organizational Payee
Health Insurance Enrollment
Clothing donations
Cellphone/tablet assistance
Group therapy
Day program
Life skills/Recovery groups
How did you hear about us?
*
Referral
Search engine/web
Social media
Word of mouth
Submit
Should be Empty: