Housing Intake Assessment
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Email
*
example@example.com
Client's Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Client's Gender
*
Male
Female
Transgender
Client's Race
*
Caucasian
African American
Hispanic
Asian
American Indian/ Native American
Islander
Other
Representative's Name (Case Manager) If none, use you First and Last name
*
First Name
Last Name
Client's/ Representative Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to text/ leave a voice message on with the number provided?
*
Yes
No
Client's Current Living Situation:
*
Living with a friend
Living in a car
Living in a Shelter
Living on the street
Incarcerated
Hospital/ Facility
Shared Housing/ Group Home
Other
Date
*
-
Month
-
Day
Year
Date
How will the Client pay?
*
SSI/ SSDI
Retirement
Voucher
Organization Funding
Job
Other
How much income do you receive monthly? If none please type NONE
*
Income Verification Documents
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List any Medications you are currently taking
Does the client suffer from mental illness? (Your answer to this question does not disqualify you from our Program & Services)
*
Yes
No
If answered yes, list mental diagnosis. If none, type NONE
*
Yes
No
Is the Client disabled? (Your answer to this question does not disqualify you from our Program & Services)
Yes
No
List Disability(s), If none, Type NONE
*
Does the Client require a Handicap Accessible Living environment?
*
Yes
No
Is the Client an ex-offender
*
Yes
No
Has the Client been convicted of Sexual Offense? (Your answer to this question does not disqualify you from our Program & Services)
*
Yes
No
With 1000ft restriction
Without 1000ft restriction
Are you currently on Probation or Parole? (Your answer to this question does not disqualify you from our Program & Services)
*
Yes
No
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol? (Your answer to this question does not disqualify you from our Program & Services)
*
Yes
No
Select all of the services the Client is requesting:
*
Transportation Assistance
Job Placement
Application for SNAP benefits
Application for SSI/ SSDI
Organizational Payee
Health Insurance Enrollment
Clothing Donation
Cellphone / Tablet Assistance
Group Therapy
Day Program
Life Skills/ Recovery Groups
How did you hear about us?
*
Word Of Mouth
Referral
Search Engine/ Online Web
Social Media
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