Freedom's Corner 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.
Client's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Representative's Name (If none type "N/A")
*
First Name
Last Name
Representative's Email
*
example@example.com
Representative's Organization
*
Client's Present Living Environment
*
Please Select
Living with family
Living with friend
Living in car
Living at a shelter
Living on the street
Hospital/Facility
Incarcerated
Shared Housing/Group Home
Other
Please select one
Do we have permission to text/leave a message on the number provided?
*
Yes
No
Please submit a copy of your identification
*
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Client's Birthdate
*
-
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
Organization Funding
Retirement
Job
Other
Client's Monthly Income (If None type "NONE")
*
Please Provide Proof of Income
*
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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
How did you hear about us?
*
Google
Referral
Social media
Word of Mouth
Flyer
Submit
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