Supportive Housing Intake Assessment

Supportive Housing Intake Assessment

Complete all fields to join our waitlist
Client's Name*

First NameLast Name
Gender*

MaleFemaleOther
Date of Birth*

MonthDayYear
Date
Phone Number*
Do we have permission to text/leave a message on the number provided?*

YesNo
Email Address*
example@example.com
Race*

African AmericanCaucasianHispanicAsianAmerican Indian/Native AmericanIslander
Representative's Name*

First NameLast Name
Rep's Organization (ex: Sober home, VA, Nursing home, etc)*
Client's Current Living Situation*

Living w/a family memberLiving w/a friendLiving in a careLiving in a shelterIncarceratedNursing facility/HospitalLiving on the streetShared housing/Group home
Occupation if any*
What type of room does the client prefer?*

SharedPrivate
When does the client need to be housed?*

MonthDayYear
Date
How will the client pay?*

SSI/SSDIOrganization FundingRetirementVoucherJob paymetOther
How much income do you receive monthly? If none, please type NONE.*
Are you disabled?*

YesNo
List disability(ies)?*
Do you consume alcohol?*

YesNo
Does the client require a Handicap Accessible living environment?*

YesNo
Is the client 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)?*

YesNoWith 1000ft restrictionWithout 1000ft restriction
Are you currently on Probation or Parole?*

YesNo
Do you agree to a background check (iCORI)?*

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

YesNo
Are you taking any form of medications?
Will the client have children living with them? (Please list ages)*
Select all of the services you are requesting.*

Job PlacementTransportationApply for SSI/SSDIHealth Insurance EnrollmentClothing DonationApply for SNAP benefitsDay ProgramGroup Therapy/Recovery groupOther
How did you hear about us?*

ReferralSearch Engin/WebsiteWord of MouthSocial Media
Terms & Conditions

Applicant Acknowledgment Statement
I understand that all personal information provided in this application will remain strictly confidential and used solely for the purpose of applying for shared housing accommodation through this organization. This organization does not sell, share, or resell personal data under any circumstances.

I confirm that all the details submitted in this form are true, complete, and accurate to the best of my knowledge. I acknowledge and accept that this application does not guarantee placement and is subject to further review.

Furthermore, I release this organization from any liability and agree to hold it harmless against any claims, expenses, damages, or legal actions arising from the information submitted herein.
Client Signature

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Date
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Supportive Housing Intake Assessment

Terms & Conditions