Client Intake Form
Client Information
:
Housing Needs & Background
Full Name
*
First Name
Last Name
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about us?
*
Please Select
Case Manager
Social Worker
Housing Specialist
Other
Please Specify
*
Do you currently have a case manager or social worker supporting you? If so, please provide their name and phone number.
Have you lived in a community/shared housing space in the past?
Yes
No
Are you currently participating in a daily/weekly program, work or educational program?
Yes
No
Do you currently have income or benefits that would support your monthly rent?
Yes
No
What is your main source of income?
Are you willing to follow house rules (i.e. no drugs, no alcohol, no unapproved house guests, cleanliness, etc.)?
Yes
No
Do you require any daily living assistance (i.e. cleaning, cooking, hygiene, etc.)?
Yes
No
Are you currently prescribed to and taking medication(s)?
Yes
No
Are you currently on parole or probation?
*
Yes
No
Have you been convicted of a felony?
*
Yes
No
What are your short-term goals?
What are your long-term goals?
What is your preferred move-in date?
-
Month
-
Day
Year
Date
Please give an emergency contact person:
Rows
Full Name
Address
Contact Number
1
Is there anything else you would like to share?
Submit
Should be Empty: