Information Request Form

Supportive Housing Intake Application

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E-mail*
example@example.com
Client's Name*

First NameLast Name
Client's Gender*

MaleFemaleTransgender
Client's Phone Number*

Area CodePhone Number
Do we have permission to text/leave messages on the number provided?*

YesNo
Race*

CaucasianAfrican AmericanHispanicAsianAmerican Indian/ Native AmericanIslanderTwo or More RacesOther
Date of Birth

MonthDayYear
Date
Representative's Name*

First NameLast Name
Rep's Organization (ex: United Way, VA, etc.)*
Client's Current Living Situation*

Living w/ a friendLiving in a carLiving in a shelterIncarceratedHospital/FacilityShared Housing/Group Home
What type of room does the client prefer?*

SharedPrivateShared w/ Private Bathroom
When does Client need to be placed?*

MonthDayYear
Date
How will the client pay?*

SSI/SSDIRetirementVoucherOrganization FundingJobOther
How much income do you receive monthly? If none please type NONE*
Does the client suffer from mental illness?*

YesNo
If answered yes, list mental diagnoses.
Are you disabled?

YesNo
If Yes, List Disability(s)
Does client require a Handicap Accessible living environment?*

YesNo
Is the client an ex-offender?*

YesNo
Has 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 Probation or Parole?*

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

YesNo
If Yes, list drug of choice.
Will the client have children living with them?*

YesNo
If Yes, (Please list ages)
Select all of the services you are requesting.*

Transportation AssistanceJob PlacementApply for SNAP benefitsApply for SSI/SSDIOrganizational PayeeHealth Insurance EnrollmentClothing DonationCellphone/Tablet AssistanceGroup TherapyDay ProgramLife Skills/Recovery GroupsNone of the AboveOther
How did you hear about us?*

ReferralSearch Engine/WebSocial MediaWord of Mouth
Signature

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Supportive Housing Intake Application