Mattie Louise Housing Client Assessment
Please fill out this form to help us provide you with the best assistance possible.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Client's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do We Have Permission To Text or Leave A Message On The Number Provided?
*
Yes
No
Email Address
*
example@example.com
Client's Gender
*
Male
Female
Transgender
Other
Race
*
Caucasian
African American
Hispanic
Asian
Other
Representative's Name
*
First Name
Last Name
Organization Representative Works For ( VA, United Way etc.)
*
Representative Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Current Living Situation
*
Living With A Friend
Living in A Car
Living in a Shelter
Living on the Street
Hospital/Facility
Shared Housing/ Group Home
What Type of room does the client prefer?
*
Shared
Private
How will the Client Pay?
*
SSI/SSDI
Retrirement
Voucher
Organization Funding
Job
Other
How Much Income Do you Receive Monthly? If None Type None
*
Does The Client Suffer From A Mental Illness?
*
Yes
No
If Yes, Please List Mental Diagnosis
*
Are You Disabled?
*
Yes
No
List Your Disability.
*
Does The Client Require A Handicap Accessible Living Environment?
*
Yes
No
Is The Client An Ex Offender?
*
Yes
No
Have You Been Convicted As A Sex Offender? (Your Answer Does Not Disqualify You From Our Program Or Services.)
*
Yes
No
With 1000ft Restriction
Without 1000ft Restriction
Are You Currently On Probation or Parole?
*
Yes
No
Do You Need Help With Recovering From Opioid(s)And /Or Other Drugs or Alcohol?
*
Yes
No
Will The Client Have Children Living With Them ( List Ages)
*
Select All Services You Are Requesting
*
Transportation
Job Placement
Apply For Snap Benefits
Apply for SSI/SSDI
Organizational Payee
Health Insurance Enrollment
Clothing Donation
Cell Phone / Tablet Assistance
Group Therapy
Day Program
Life Skills/Recovery Group
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How Did You Hear About Us?
*
Referral
Search Engine/Web
Social Media
Word of Mouth
Other
Submit
Should be Empty: