Intake Assessment
Name
First Name
Last Name
Age
Sex
Male
Female
Email
example@example.com
Do you have a working phone where we can contact you?
If yes, please provide. If no, how may we contact you?
Please provide your Case Manager’s name, agency, phone number and email.
If none, please enter N/A
Are you able to live independently without daily assistance?
Yes- I’m independent
No- I need assistance
Do you currently receive help with daily activities? (Cleaning, cooking, hygiene, etc)
Yes
No
Do you have a steady source of income?
Yes
No
What is your main source of income?
SSI
SSDI
VA Benefits
Employment
Other
What is your estimated monthly income?
We may ask for confirmation
Do you receive food stamps/ EBT (SNAP benefits)?
Yes
No
Do you have an award letter? (Benefit recipients)
Yes
No
N/A
Do you have a mental health diagnosis?
If no, please type N/A. If yes, please provide details and medications
Are you currently taking any prescribed medications?
Yes
No
N/A
Do you have any difficulties accessing your medications? (Costs, transportation, insurance, etc)?
If none, type N/A
Are you open to shared rooming? (2 per room)
Yes
No
Have you ever been evicted from a previous residence?
Yes
No
Have you ever been convicted of a felony?
Yes
No
Are you a registered sex offender?
Yes
No
Are you willing to follow house rules (e.g. no drugs, no unapproved guests, quite hours, cleanliness, etc)?
Yes
No
Do you smoke?
Yes
No
Do you have any pets?
Yes
No
Why are you seeking housing at this time?
Is there anything else you’d like us to know?
If no, type N/A
Submit
Should be Empty: