Freedom's Corner Intake Assessment

Freedom's Corner Intake Assessment

Please complete this form accurately to help us assess your housing needs and determine eligibility.
Client's Name

First NameLast Name
Client's Email
example@example.com
Client's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Representative's Name (If none type "N/A")

First NameLast Name
Representative's Email
example@example.com
Representative's Organization
Client's Present Living Environment
Please select one
Do we have permission to text/leave a message on the number provided?
Please submit a copy of your identification

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Client's Birthdate

MonthDayYear
Date
Client's Gender
Client's Race
Client's Room Preference
Client's Method of Payment

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?
If applicable, describe the condition(s) below. Otherwise, type "N/A."
Does client have a physical, mental, or developmental disability?
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)?
Has client ever been convicted of a sex offense? Note: Your response will not automatically disqualify you from our program or services.
Presently on probation or parole?
Does client require assistance with substance use recovery (including opioids, alcohol, or other drugs)?
Will the client have any children living with them?
Which of the following resources is the client seeking? (Select all that apply)
How did you hear about us?
Should be Empty: