Georgia's Best Haven Client Intake Form

Georgia's Best Haven Client Intake Form
Date

MonthDayYear
Date
Referral Source (if any):
- Full Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Age
- Gender
  
  Other
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Current Living Situation
  
  Other
- Number of Children:
- Ages if Children:
- Do you need childcare?
- Are all children under age 5?
- Any allergies, medical needs, or special accommodations?
- Employment Status
  
  Other
- Source of income (check all that apply)
  
  Other
- Monthly Income Amount $:
- Prefered Location
- Room Typed Requested
- Move-In Date Requested
- Any mobility or accessibility needs?
- If YES, Please explain
- Have you ever lived in shared housing before?
- Do you have a case manager, probation officer, or support worker?
- If yes, list name + contact:
- Background concerns we should be aware of (no judgment, safety only):
  
  Other
- Email
  example@example.com
- Relationship
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- I understand that Georgia’s Best Haven provides shared housing with house rules, expectations, and program guidelines to maintain a safe and clean environment for all residents. I agree to follow all rules and participate in the intake process honestly.
- Client Signature
- Date Today
  
  MonthDayYear
  Date
- Should be Empty: