Supportive Housing Intake Form
Please fill out the following information to join waitlist.
Client Full Name
*
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date
Client Gender
*
Male
Female
Transgender
Client Race
*
Caucasian
African American
Hispanic
American Indian/ Alaskan Native
Asia/ Pacific Islander
Other
Client Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client Email
example@example.com
Representative Name
First Name
Last Name
Representative Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Representative Email
example@example.com
Representative Organization (VA, United Way, Hospital, etc.)
Do we have permission to text/leave message on the phone number(s) provided?
*
Yes
No
Client current living situation
*
Living in shelter
Living in car
Living on the streets
Living with family/friends
Incarcerated
Hospital/Facility
Foster Care/ Group Home
Shared Housing
Other
What type of room client prefer?
*
Private Room
Shared Room
When does client need to be placed?
*
-
Month
-
Day
Year
Date
How will client pay? (income will be verified)
*
Job
SSI/SSDI
Retirement
Voucher
Organization Funding
Other
How much is client monthly income?
*
Does client suffer from mental illness?
*
Yes
No
If yes, list diagnosis
Does client have any disabilities?
*
Yes
No
If yes, list those disabilities
Does client require wheelchair accessibilites?
*
Yes
No
Is the client an ex-offender?
*
Yes
No
Have client been convicted as a Sex Offender? (Your answer to this question does not disqualify you from our program & services)
*
Yes
No
with 1000ft restriction
without 1000ft restriction
Is Client currently on parole or probation? (if yes, list reason)
*
Do client need help with recovering from Opioids(s) and/or other drugs and alcohol?
*
Yes
No
Will client have children living with them? (if yes, list ages and gender)
*
Select all services client need?
*
Transportation Assistance
Job Placement
Apply for SNAP benefits
Organizational Payee
Health Insurance Enrollment
Life Insurance Enrollment
Clothing Donation
Cellphone/Tablet Assistance
Group Therapy
Day Program
Life Skills/ Recovery Group
None
How did you hear about us?
*
Referral
Search Engine/Web
Social Media
Word of Mouth
Other
Submit
Should be Empty: