Supportive Housing Intake Assessment
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Email
*
example@example.com
Full Name
*
First Name
Last Name
Representative's Name
*
First Name
Last Name
Rep's Organization (ex. United Way, VA, etc)
Gender
*
Female
Male
Transgender
Client's 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
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?
SSI/SSDI
Retirement/VBA
Voucher
Organization Funds
Job
Other
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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