Supportive Housing Intake Assessment
Is Our Supportive Housing Program the Right Fit for You?
Client Information
Please provide the client's personal and contact details.
Client's Email Address
*
example@example.com
Client's Gender
*
Male
Female
Other
Client's Full Name
*
First Name
Last Name
Representative's Full Name
*
First Name
Last Name
Representative's Organization
*
Client's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Permission to text/leave message?
*
Yes
No
Race
*
Caucasian
African American
Hispanic
Asian
American Indian/Native American
Islander
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Housing Needs
Tell us about your current living situation and housing preferences.
Current Living Situation
*
Living w/a friend
Living in a car
Living in a shelter
Living on the street
Incarcerated
Hospital/Facility
Shared Housing/Group Home
Other
Room Preference
*
Shared
Private
When does client need to be placed?
*
-
Month
-
Day
Year
Date
Financial Information
Help us understand the client's financial situation.
How will the client pay?
*
SSI/SSDI
Retirement
Voucher
Organization Funding
Job
Other
Monthly Income (If none type NONE)
*
Health & Background
Provide health and background information to ensure appropriate placement.
Does the client suffer from mental illness?
*
Yes
No
List mental diagnoses
Are you disabled?
*
Yes
No
List disability(s)
Does client require a Handicap Accessible living environment?
*
Yes
No
Is the client an ex-offender?
*
Yes
No
Have you been convicted as a Sex Offender? (Your answer does not disqualify you from our program & services.)
*
Yes
No
With 1000ft restriction
Without 1000ft restriction
Currently on Probation or Parole?
*
Yes
No
Need help recovering from Opioids and/or drugs and alcohol?
*
Yes
No
Services Requested
Select all services you are requesting.
Select all services requested
*
Transportation Assistance
Job Placement
Apply for SNAP benefits
Apply for SSI/SSDI
Organization Payee
Health Insurance Enrollment
Clothing Donation
Cellphone/Tablet Assistance
Group Therapy
Day Program
Life Skills/Recovery Groups
Referral Information
Let us know how you found out about our services.
How did you hear about us?
*
Referral
Search Engine/Web
Social Media
Word of Mouth
Other
Submit Application
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