Supportive Housing Intake Assessment
Join Our Waitlist
Email
*
example@example.com
Full Name
*
First Name
Last Name
Representative's Name
*
First Name
Last Name
Rep's Organization / How did you hear about us? (ex. United Way, VA, etc)
Gender
*
Female
Male
Refuse to Answer
Other
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to text/leave a message on the number provided?
Yes
No
Race
*
Caucasian
African American
Hispanic
Asian
American Indian/Native American
Islander
Date of Birth
*
-
Month
-
Day
Year
Date
Client's Current Living Situation
Living with informal support (friends/family)
Living in a car
Living in a shelter
Living on the street
Hospital/Facility
Shared Housing/Group Home
Downsizing
Please tell us your story and be sure to include hardships and difficulties that would help us as we look for opportunities to support you.
How long do you anticipate needing housing ?
Please Select
Short-Term (1-3 months)
Medium-Term (3-12 months)
Long-Term (1+ year)
Preferred Placement Location in SC
Greenville
Spartanburg
Greer
Fountain Inn
Laurens
Open Availability
What is your monthly budget for a semi-private or private room?
Please Select
$750-$950
$1100-$1500
Are you wanting a semi-private or private room?
*
Shared/Semi-Private
Private
When does client need to be placed?
*
-
Month
-
Day
Year
Date
Does your household have income assistance or benefits from the funding sources listed below?
Self-Employed (you work for yourself)
Employent from third party (you work for a company)
Retirement from Social Security
Disability or death benefits other than Social Security
Supplemental Security Income (SSI)
Social Security Disability Income (SSDI)
Unemployment Benefits
Unemployed
Community Assistance from an Organization
How much income do you receive monthly? If none please type NONE
Does the client suffer from mental illness?
*
Yes
No
If answered yes, list mental diagnoses
*
Are you disabled?
Yes
No
List disability(s)
*
Does client require a Handicap Accessible living environment?
Yes
No
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?
Yes
No
Before submitting this application, please confirm that you understand the following program requirement:
Our housing program requires residents to have a stable source of income (such as SSI, SSDI, private pay, or another approved funding source) that can be used toward housing expenses.
Do you understand and meet this eligibility requirement?
Yes
No
How did you hear about us
Referral
Search Engine/Web
Social Media
Word of Mouth
Submit
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