Supportive Housing Intake Form

Supportive Housing Intake Form

Please fill out the following information to join waitlist.
Client Full Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Client Gender*

MaleFemaleTransgender
Client Race*

CaucasianAfrican AmericanHispanicAmerican Indian/ Alaskan NativeAsia/ Pacific IslanderOther
Client Phone Number
Please enter a valid phone number.
Client Email
example@example.com
Representative Name

First NameLast Name
Representative Phone Number
Please enter a valid phone number.
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?*

YesNo
Client current living situation*

Living in shelterLiving in carLiving on the streetsLiving with family/friendsIncarceratedHospital/FacilityFoster Care/ Group HomeShared HousingOther
What type of room client prefer?*

Private RoomShared Room
When does client need to be placed?*

MonthDayYear
Date
How will client pay? (income will be verified)*

JobSSI/SSDIRetirementVoucherOrganization FundingOther
How much is client monthly income?*
Does client suffer from mental illness?*

YesNo
If yes, list diagnosis
Does client have any disabilities?*

YesNo
If yes, list those disabilities
Does client require wheelchair accessibilites?*

YesNo
Is the client an ex-offender?*

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

YesNowith 1000ft restrictionwithout 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?*

YesNo
Will client have children living with them? (if yes, list ages and gender)*
Select all services client need?*

Transportation AssistanceJob PlacementApply for SNAP benefitsOrganizational PayeeHealth Insurance EnrollmentLife Insurance EnrollmentClothing DonationCellphone/Tablet AssistanceGroup TherapyDay ProgramLife Skills/ Recovery GroupNone
How did you hear about us?*

ReferralSearch Engine/WebSocial MediaWord of MouthOther
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