New Path Solutions Client Intake Form

New Path Solutions Client Intake Form

Please complete this form to help us understand your housing needs and eligibility.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Living Situation*
Population Category (check all that apply)

FamilySenior (age 62+)VeteranIndividualDisabledOther
Maximum Monthly Rent Budget
Primary Income Source
Credit/Background Concerns
Current Benefits/Vouchers

Section 8HUD-VASHMedicaidSNAPSSI/SSDIHousing VoucherVeterans BenefitsNoneOtherOther
Move-In Timeline
Physical Health Conditions

Mobility limitationsChronic painRespiratory conditionHeart conditionVision impairmentHearing impairmentOtherOther
Mental/Behavioral Health

AnxietyDepressionPTSDBipolar disorderSubstance use disorderCognitive impairmentOtherOther
Currently Receiving Treatment?
Special Housing Accommodations
Name of Social Worker/Case Manager*
Organization/Agency*
Your Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Additional Notes
Client Consent Confirmation*

I consent
Additional Health Notes
Your Email
example@example.com