Supportive Housing Intake Application
Join Our Waitlist
E-mail
*
example@example.com
Client's Name
*
First Name
Last Name
Client's Gender
*
Male
Female
Transgender
Client's Phone Number
*
-
Area Code
Phone Number
Do we have permission to text/leave messages on the number provided?
*
Yes
No
Race
*
Caucasian
African American
Hispanic
Asian
American Indian/ Native American
Islander
Two or More Races
Other
Date of Birth
-
Month
-
Day
Year
Date
Representative's Name
*
First Name
Last Name
Rep's Organization (ex: United Way, VA, etc.)
*
Client's Current Living Situation
*
Living w/ a friend
Living in a car
Living in a shelter
Incarcerated
Hospital/Facility
Shared Housing/Group Home
What type of room does the client prefer?
*
Shared
Private
Shared w/ Private Bathroom
When does Client need to be placed?
*
-
Month
-
Day
Year
Date
How will the client pay?
*
SSI/SSDI
Retirement
Voucher
Organization Funding
Job
Other
How much income do you receive monthly? If none please type NONE
*
Does the client suffer from mental illness?
*
Yes
No
If answered yes, list mental diagnoses.
Are you disabled?
Yes
No
If Yes, List Disability(s)
Does client require a Handicap Accessible living environment?
*
Yes
No
Is the client an ex-offender?
*
Yes
No
Has 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 Probation or Parole?
*
Yes
No
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?
*
Yes
No
If Yes, list drug of choice.
Will the client have children living with them?
*
Yes
No
If Yes, (Please list ages)
Select all of the services you are requesting.
*
Transportation Assistance
Job Placement
Apply for SNAP benefits
Apply for SSI/SSDI
Organizational Payee
Health Insurance Enrollment
Clothing Donation
Cellphone/Tablet Assistance
Group Therapy
Day Program
Life Skills/Recovery Groups
None of the Above
Other
How did you hear about us?
*
Referral
Search Engine/Web
Social Media
Word of Mouth
Signature
Submit
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