Supportive Housing Intake Assessment
Join the waitlist. Apply for our independent living housing program by providing your details and service needs below. Assessments are processed the day of submission.
Client Information
Please provide the client's personal details.
Client's Full Name
*
First Name
Last Name
Client's Email Address. If client doesn't have an email, please type NONE.
example@example.com
Client's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to text or leave a message on the number provided?
*
Yes
No
Client's Gender
*
Male
Female
Transgender
Client's Race (Select all that apply)
*
American Indian or Alaska Native
Asian
Black or African American
Caucasian
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Client's Current Living Situation (Select all that apply)
*
Living with a friend
Living in car
Living in shelter
Living on street
Incarcerated
Hospital/Facility
Shared Housing/Group Home
What type of room does the client prefer?
*
Shared
Private
When does client need to be placed?
*
-
Month
-
Day
Year
Date
How will the client pay? (Select all that apply)
*
SSI/SSDI
Retirement
Voucher
Organization funding
Job
Other_________________
How much income do you receive monthly? If none, please type NONE.
*
Does the client suffer from mental illness?
*
Yes
No
If yes, please list mental health diagnoses.
Is the client disabled?
*
Yes
No
If yes, please list disabilities. If none, please type NONE.
Does the client require a handicap accessible living environment?
*
Yes
No
Have you been convicted as a Sex Offender? (Your answer to this question does not disqualify you from our program & services)
*
Yes
No
With 1000 ft restriction
Without 1000 ft restriction
Are you currently on probation or parole?
*
Yes
No
Do you need help with recovering from opioids and/or other drugs and alcohol?
*
Yes
No
Will the client have children living with them? (Please list ages)
*
Select all of the services you are requesting:
*
Transportation assistance
Job placement
Apply for SNAP Benefits
Apply for SSI/SSDI
Organizational Payee
Health Insurance Enrollment
Clothing Donation
Cellphone/Tablet Assistance
Group Therapy
Day Program
Life Skills/Recovery Groups
Job Interviewing Skills
How did you hear about us?
*
Referral Search
Search Engine/Internet
Social Media
Word of Mouth
Representative Information
Please provide the details of the client's representative, if applicable.
Representative's Full Name
First Name
Last Name
Representative's Organization (e.g., Salvation Army, VA, etc.)
Representative's Phone Number
Representative's Email Address
Someone will call you the same day the assessment is submitted.
Submit Application
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