Primus Way Intake Assessment
Submit your application today
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Client's Gender
*
Male
Female
Transgender
Do we have permission to text/leave a message on the number provided?
*
Yes
No
Race
African American
Hispanic
Caucasian
Asian
American Indian/Native American
Pacific Islander
Other
Client's Current Living Situation
*
Living in a shelter
Living in car
Living with a friend
Hospital/Facility
Incarcerated
Shared Housing/Group Home
Other
When does the client need to be placed? (If no space is available you will be added to the waitlist)
*
-
Month
-
Day
Year
Date
Does this client suffer from mental illness?
*
Yes
No
If answered yes, list mental diagnoses
Is the client disabled?
*
Yes
No
List disabilities
How will the client pay?
*
SSI/SSDI
Retirement
Voucher
Organization Funding
Job
Other
What is the client's monthly income? If none please type NONE
*
Has the client been convicted of a felony?
*
Yes
No
If yes, please briefly explain:
*
Is the client currently on Probation or Parole?
*
Yes
No
Does the client need help with recovering from Opioid(s) and/or other drugs and alcohol?
*
Yes
No
Select all of the services the client is requesting.
Apply for SNAP benifits
Health Insurance Enrollment
Transportation Assistance
Clothing Donations
Apply for SSI/SSDI
Other
How did you hear about Us
*
Referral
Search Engine/Web
Social Media
Other
Submit
Should be Empty: