Supportive Housing Intake Assessment
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E-mail
*
example@example.com
Client's Gender
*
Male
Female
Transgender
Full Name
*
First Name
Last Name
Representative's Name
*
First Name
Last Name
Rep's Organization (ex: United Way, VA, etc)
*
Phone Number
*
Format: (000) 000-0000.
Do we have permission to text/leave a message on the number provided?
*
Yes
No
Race
*
Caucasian
African American
Hispanic
Asian
American Indian/Native American
Islander
Date Of Birth (Month / Date / Year)
*
Current Living Situation
*
Living w/ a friend
Living in a car
Shelter
Living on the street
Incarcerated
Hospital/Facility
Shared Living/Group Home
If Homeless (how long) & (Reason )
*
When does client need to be placed in housing
*
-
Month
-
Day
Year
Date
Private or Shared Room
*
Private
Shared
How Do You Plan To Pay?
*
SSI/SSDI
Retirement
Voucher
Organization Funding
Job
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?
*
Yes
No
Are You Able to Live Independently? (Manage Own Hygiene, Medication, Food)
*
Yes
No
Are you an ex-offender?
*
Yes
No
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)
*
Yes
No
Are you currently on Probation or Parole?
*
Yes
No
Do you Smoke ?
*
Yes
No
Do you drink Alcohol?
*
Yes
No
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?
*
Yes
No
Type option 3
Type option 4
Will the client have children living with them? (Please list ages)
*
Do you have a support team?
*
Family
Friend
Spouse
Sponsor
None
Select all of the services you are requesting.
*
Transportation Assistance
Job Placement
Apply for Snap Benefits
Apply for SSI/SSDI
Organizational Payee
Health Insurance Enrollment
Clothing Donation
Cellphone/Tablet Assistance
Group Therapy
Day Program
Life Skills/Recovery Groups
How did you hear about us?
*
Referral
Search Engine/Web
Social Media
Word of Mouth
Confirm Income
*
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