Supportive Housing Intake Form

Supportive Housing Intake Form

Please fill out this form to help us understand your needs and provide appropriate housing support.
Name*

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Gender*

FemaleMaleOther
Client Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Case Worker/Rep Name *

First NameLast Name
Case Worker/Rep Phone Number*
Please enter a valid phone number.
Case Worker/Rep Email *
example@example.com
Additional Information
Emergency Contact

First NameLast Name
Emergency Phone Number
Please enter a valid phone number.
What is your living situation now?*

Living with a friendLiving in a carShelterHomelessHospital/FacilityShared HousingOther
Do you have any disabilities?*

yesno
Does the client require a Handicap Accessible living environment?**
If yes, please describe your disability or special needs*
Do you have any history of substance abuse?**

yesno
Have you been convicted as a Sex Offender?**

yesno
If yes, please provide details**
Do you have any mental health conditions?**

yesno
If yes, please provide details**
Current Income*

EmployedSSI/SSDIRetirementVoucherShared HousingOther
Monthly Income Amount *
Do you have health insurance?**

yesno
Additional comments or needs*
When does the client need to be placed?

MonthDayYear
Date
Are you currently on Probation or Parole?**
How did you hear about us?**

ReferralSearch Engine/WebSocial MediaOther
Acknowledgment:

I understand that being on the waitlist does not guarantee a room and that I will be contacted when a room becomes available. I agree to promptly respond to any communication regarding apartment availability.
Date

MonthDayYear
Date
Signature
Should be Empty:

Supportive Housing Intake Form

Additional Information