Client Intake Form
Date
-
Month
-
Day
Year
Agent/Representative Name/How do you hear about us?
Move-in date:
-
Month
-
Day
Year
Name
First Name
Last Name
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Date of Birth:
-
Month
-
Day
Year
Marital Status
Single
Married
Separated
Divorced
Race
American Indian or Alaska Native Asian
Black of African American
Hispanic or Latino Ethnicity
White or Caucasian
Other
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Next
Additional Information
Do you have your birth certificate?
Please Select
Yes
No
Do you have your social security card?
Please Select
Yes
No
Please verify your social
Do you have photo ID?
Please Select
Yes
No
Do you have medical insurance card?
Please Select
Yes
No
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Next
Housing Information
Are you currently homeless
Please Select
Yes
No
What's your current address?
Have you ever applied for
Section 8 Housing
Rental Allowance Program
Public Housing
Shelter Plus Housing
Have you ever lived in a home where you shared a bathroom and/or kitchen with people other than your family?
Please Select
Yes
No
If yes, describe in detail any problems?
Do you require any special accommodations?
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Next
Health Information
What type of health insurance do you have?
Medicaid
Medicare
Private
None
Do you have physical health conditions?
Please Select
Yes
No
If yes, list your conditions
Doctors Name & Phone Number
Do you have Mental Health issues?
If yes, please list your diagnosis
Mental Health providers name & phone number
Please list current medications
Please list any allergies
Have you ever been treated for substance abuse?
If yes, list treatment provider
Do you receive injections for treatment?
If yes, what injection?
What is your drug of choice?
Have you ever tested positive for HIV/ACIDS
Please Select
Yes
No
History of injection drug use?
Please Select
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Next
Financial Information
What is your source of income?
Employment Income
General Public Assistance
Social Security Disability Income
Supplemental Social Security Income (SSI)
Do you receive any of the following benefits
Food Stamps
Employment Benefits
Veteran Benefits
Pension
No financial income
If yes, to any option above what's the amount received monthly?
Do you have a bank account?
Please Select
Yes
No
If yes, please list name of bank?
Have you ever filed for bankruptcy?
If yes, when?
Please list any debts you owe
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Next
Financial Information II
Is any agencies providing housing fund on your behalf?
Please Select
Yes
No
If yes, list agency
Do you have a payee?
Please Select
Yes
No
If yes, please provide name & number
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Next
Employment Information
Who is your current employer?
Company Name:
Address:
Job Title:
Start Date:
Hourly Pay:
Supervisors Name & Phone Number
Full Time or Part Time
Please list your previous employer, if you have been at your current employer less than 6 months:
Address:
Job Title:
Start Date:
Hourly Pay
Supervisors Name & Phone Number
Full Time or Part Time
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Next
Education Information
Whats your highest level of education?
Some high school?
Last grade completed?
High School Diploma
Please Select
Yes
No
Some College
Please Select
Yes
No
Associate degree
Please Select
Yes
No
Bachelor's degree
Please Select
Yes
No
Do you have a GED?
Please Select
Yes
No
Do you have a copy of your Diploma or GED?
Please Select
Yes
No
Do you have difficulty reading/writing?
Please Select
Yes
No
Please list name of schools?
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Next
Legal History
Have you ever been arrested?
Please Select
Yes
No
If yes, list your most recent charges
Are you currently on Probation or Parole?
Have you ever been incarcerated
Please Select
Yes
No
Most recent incarceration?
Longest period?
Do you agree that the questions above have been answered truthfully?
Please Select
Yes
No
Submit
Should be Empty: