Ambassadors Grove Intake Form

Personal Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Who is filling out this form today?
Eligibility & Pre-Screening Questions
Are you (the client) currently homeless or at risk of losing your housing?
Why do you (the client) need housing at this time?
How long have you (the client) been displaced or without stable housing?
Do you (the client) have a monthly income or benefits?
What type(s) of income or benefits do you (the client) currently receive?

Other
If “Other,” please describe your income type
Do you (the client) have any pending legal issues, probation, or parole supervision?
Please list any current legal issues, probation, or parole details.
Are you (the client) currently working with a case manager or support agency?
If you (the client) have a case manager, what is their name and contact information?
Do you (the client) have any immediate safety concerns or medical needs?
Please describe any immediate safety concerns or medical needs.
How often are you (the client) hospitalized or receiving medical/mental health treatment?
What are your (the client) long-term goals?
Where were you (the client) living before (for references)?
Has another home, shelter, or program completed an assessment on you (the client)?
What were the results of that assessment?
Client Housing & Referral Information
Client Date of Birth
Current Housing Situation
“Describe where the client is staying right now…”
Main Barriers or Challenges
“Mental health, income, background, transportation, etc.”
Client’s Immediate Needs
“Support services, stability, discharge planning, etc.”
Reason for Referral
Additional Notes (Optional)
Professional Referral Section
Your Name (Professional)

First NameLast Name
Agency / Organization Name
Your Phone Number (Professional)
Please enter a valid phone number.Format: (000) 000-0000.
Your Email (Professional)
example@example.com
Client ID / Case Number
Upload Any Supporting Documents (Optional)

Cancelof
Consent & Submission
Consent to Submit
Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Personal Information

Eligibility & Pre-Screening Questions

Client Housing & Referral Information

Professional Referral Section

Consent & Submission