CLIENT INTAKE FORM
SECTION 1: PERSONAL INFORMATION
Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Gender:
SSN (Last 4 digits):
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
Current Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SECTION 2: EMERGECY CONTACT
Name
First Name
Last Name
Relationship:
Phone number:
SECTION 3: HOUSING NEEDS
Reason for seeking housing:
Preferred move-in date:
-
Month
-
Day
Year
Date
Accessible housing needs:
Yes
No
If yes, please explain:
Housing voucher:
Yes
No
If yes, voucher provided by:
SECTION 4: MEDICAL & SUPPORT NEEDS
Health diagnosis:
Yes
No
If yes, please state diagnosis:
Under doctor's care: If yes list Dr. name & number:
List all prescribed medications:
Assistance needs: Ex. bathing, feeding, dressing, etc
SECTION 5: LEGAL & FINANCIAL INFORMATION
Monthly income:
Source of income:
Payee or Guardian (Y/N name/phone):
Felony conviction (Y/N explanation):
SECTION 6: ADDITIONAL INFORMATION
Pets (Y/N and how many):
Do you smoke (Y/N):
Private room needed (Y/N and reason):
Willing to participate in services and/or activities (Y/N):
Signature
Date
-
Month
-
Day
Year
Date
Staff Reviewed By:
Date
-
Month
-
Day
Year
Date
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Submit
Submit
Should be Empty: