Rae Stephen Living Housing Intake Assessment

Full Name* This field is required.

First Name

Last Name

Client's Gender* This field is required.

Male

Female

Transgender

Date of Birth* This field is required.

Date

Race* This field is required.

Caucasian/White

African American/Black

Hispanic/Latino

Asian

American Indian

Islander

Email* This field is required.

example@example.com

Client's Phone Number* This field is required.

Please enter a valid phone number.

Do we have permission to text/leave a message on the number provided?* This field is required.

Yes

Representative's Name* This field is required.

First Name

Last Name

Rep's Organization (ex: Piedmont, VA, etc)* This field is required.

Emergency Contact Name:* This field is required.

Emergency Contact Phone Number:* This field is required.

Relationship to Emergency Contact:* This field is required.

Best time to reach you?* This field is required.

Morning

Afternoon

Evening

Client's preferred room type?* This field is required.

Shared

Private (if available)

Client's Current Address:* This field is required.

Client's Current Living Situation* This field is required.

Living in a car

Living w/ a friend

Living in a shelter

Living on the street

Living in hotel

Shared Housing

Incarcerated

Desired Move-In Date* This field is required.

Date

Desired Length of Stay:* This field is required.

Are you open to scheduled room inspections to maintain property standards?* This field is required.

Yes

Do you currently have furniture or personal belongings that will need space (Clients are only allowed 2 personal bags)? If yes, please provide details:* This field is required.

How will client pay?* This field is required.

SSI/SSDI

Retirement

Organization Funding

Job

Other

How much income does client receive monthly? If none, please type NONE* This field is required.

Confirm Income (e.g. Award Letter, Check Stubs)*

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Does the client suffer from mental illness? (Your answer to this questions does not disqualify you from our program & services)* This field is required.

Yes

If answered yes, list mental diagnoses.* This field is required.

Are you disabled?* This field is required.

Yes

List disability(s)* This field is required.

Does client require a Handicap Accessible living environment?* This field is required.

Yes

Is the client an ex-offender?* This field is required.

Yes

Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)* This field is required.

Yes

With 1000ft restriction

Without 1000ft restriction

Are you currently on Probation or Parole?* This field is required.

Yes

Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?* This field is required.

Yes

Will the client have children living with them? (Please list ages)* This field is required.

Have your ever been evicted?* This field is required.

Yes

If yes, please provide details:* This field is required.

Are you able to live independently without daily assistance?* This field is required.

Yes

Are you willing to follow house rules and expectations (e.g no smoking in house, respect others, cleanliness)?* This field is required.

I understand this is an independent living program, not assisted living?* This field is required.

Yes

Rae Stephen Living, is a drug and alcohol free environment. Do you agree to follow this policy?* This field is required.

Yes

I acknowledge that participation is based on month to month terms and on going compliance with program guidelines:* This field is required.

Yes

I agree to pay rent on time as outlined in my housing program agreement:* This field is required.

Yes

I agree to follow all house rules and understand repeated violations may result in termination of my housing:* This field is required.

Yes

I acknowledge that Rae Stephen Living, is not liable for my personal belongings:* This field is required.

Yes

I certify that the information I have provide is accurate and truthful to the best of my knowledge:* This field is required.

Yes

Select all of the services you are requesting.

Apply for SNAP benefits

Clothing Donation

Job Placement

Housing

How did you hear about us* This field is required.

Referral

Search Engine/Web

Social Media

Word of Mouth

Typed Signature:* This field is required.

Signature* This field is required.

Today's Date* This field is required.

Date