Program Application

Supportive Housing Intake Assessment

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E-mail*
example@example.com
Client's Gender*

MaleFemaleTransgender
Full Name*

First NameLast Name
Representative's Name*

First NameLast Name
Rep's Organization (ex: United Way, VA, etc)*
Phone Number*
Do we have permission to text/leave a message on the number provided?*

YesNo
Race*

CaucasianAfrican AmericanHispanicAsianAmerican Indian/Native AmericanIslander
Date Of Birth (Month / Date / Year)*
Current Living Situation*

Living w/ a friendLiving in a carShelterLiving on the streetIncarceratedHospital/FacilityShared Living/Group Home
If Homeless (how long) & (Reason )*
When does client need to be placed in housing*

MonthDayYear
Date
Private or Shared Room*

PrivateShared
How Do You Plan To Pay?*

SSI/SSDIRetirementVoucherOrganization FundingJob
How much income do you receive monthly? If none please type NONE*
Does the client suffer from mental illness?*
If answered yes, list mental diagnoses*
Are you disabled?*
List disability(s)*
Does client require a Handicap Accessible living environment?*
Currently taking any medications?*

YesNo
Are You Able to Live Independently? (Manage Own Hygiene, Medication, Food)*

YesNo
Are you an ex-offender?*

YesNo
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)*

YesNo
Are you currently on Probation or Parole?*

YesNo
Do you Smoke ?*

YesNo
Do you drink Alcohol?*

YesNo
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?*

YesNoType option 3Type option 4
Will the client have children living with them? (Please list ages)*
Do you have a support team?*

FamilyFriendSpouseSponsorNone
Select all of the services you are requesting.*

Transportation AssistanceJob PlacementApply for Snap BenefitsApply for SSI/SSDIOrganizational PayeeHealth Insurance EnrollmentClothing DonationCellphone/Tablet AssistanceGroup TherapyDay ProgramLife Skills/Recovery Groups
How did you hear about us?*

ReferralSearch Engine/WebSocial MediaWord of Mouth
Confirm Income*

Cancelof
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Supportive Housing Intake Assessment