Housing Intake Assessment

Housing Intake Assessment

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Full Name*

First NameLast Name
Client's Gender*

MaleFemaleTransgender
Email*
example@example.com
Representative's Name*

First NameLast Name
Rep's Organization (ex: Piedmont, VA, etc)*
Client's Phone Number*
Please enter a valid phone number.
Do we have permission to text/leave a message on the number provided?*

YesNo
Race*

Caucasian/WhiteAfrican American/BlackHispanic/LatinoAsianAmerican IndianIslander
Date of Birth*

MonthDayYear
Date
Client's preferred room type?*

SharedPrivate
Client's Current Living Situation*

Living in a carLiving w/ a friendLiving in a shelterLiving on the streetLiving in hotelIncarceratedShared Housing
Desired Move-In Date*

MonthDayYear
Date
How will client pay?*

SSI/SSDIRetirementOrganization FundingJobOther
How much income does client receive monthly? If none please type NONE*
Confirm Income*

Cancelof
Does the client suffer from mental illness?*

YesNo
If answered yes, list mental diagnoses.*
Are you disabled?*

YesNo
List disability(s)*
Does client require a Handicap Accessible living environment?*

YesNo
Is the client an ex-offender?*

YesNo
Type a Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)question*

YesNoWith 1000ft restrictionWithout 1000ft restriction
Are you currently on Probation or Parole?*

YesNo
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?*

YesNo
Will the client have children living with them? (Please list ages)*
Select all of the services you are requesting.

Apply for SNAP benefitsClothing DonationJob Placement
How did you hear about us*

ReferralSearch Engine/WebSocial MediaWord of Mouth
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