Supportive Living Intake Assessment
Join Our Waitlist
Full Legal Name
*
First Name
Last Name
Client's Gender
*
Male
Female
Transgender
Date of Birth
*
-
Month
-
Day
Year
Date
Race
*
Caucasian/White
African American/Black
Hispanic/Latino
Asian
American Indian
Islander
Email
*
example@example.com
Client's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to text/leave a message on the number provided?
*
Yes
No
Representative's Name
*
First Name
Last Name
Rep's Organization (ex: Piedmont, VA, etc)
*
Emergency Contact Name:
*
Emergency Contact Phone Number:
*
Relationship to Emergency Contact:
*
Best time to reach you?
*
Morning
Afternoon
Evening
Client's preferred room type?
*
Shared
Private (if available)
Client's Current Address:
*
Client's Current Living Situation
*
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
*
-
Month
-
Day
Year
Date
Desired Length of Stay:
*
Are you open to scheduled room inspections to maintain property standards?
*
Yes
No
Do you currently have furniture or personal belongings that will need space (Clients are only allowed 2 personal bags)? If yes, please provide details:
*
How will client pay?
*
SSI/SSDI
Retirement
Organization Funding
Job
How much income does client receive monthly? If none, please type NONE
*
Copy of ID*
Browse Files
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Choose a file
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of
Confirm Income (e.g. Award Letter, Check Stubs)*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Does the client suffer from mental illness? (Your answer to this questions does not disqualify you from our program & services)
*
Yes
No
If answered yes, list mental diagnoses.
*
Are you disabled?
*
Yes
No
List disability(s)
*
Does 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 to this questions does not disqualify you from our program & 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 and alcohol?
*
Yes
No
Will the client have children living with them? (Please list ages)
*
Have your ever been evicted?
*
Yes
No
If yes, please provide details:
*
Select all of the services you are requesting.
Apply for SNAP benefits
Clothing Donation
Job Placement
Housing
How did you hear about us
*
Referral
Search Engine/Web
Social Media
Word of Mouth
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: