Housing Intake Assessment
Join Our Waitlist
Clients Name
*
First Name
Last Name
Clients Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Clients Gender
*
Male
Female
Transgender
When does the client need to be placed?
-
Month
-
Day
Year
Date
Representative name
First Name
Last Name
Representative Email Address
example@example.com
Rep's Organization
Race
African American
Caucasian
Hispanic
American Indian/ Native American
Asian
Other
Date of Birth
*
-
Month
-
Day
Year
Clients current living situation:
Living w/a friend
Living in a car
Living at a shelter
Living on the street
Incarcerated
Hospital/facility
Shared / Group home
How will the client pay :
*
SSI/SSDI
Retirement
Voucher
Job
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 diagnosis
Are you disabled ?
*
Yes
No
If answered yes, list disability(s)
Does the 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 to this question does not disqualify you from our program or services)
*
Yes
No
With 1000ft restriction
Without 1000ft restriction
Are currently on Probation or Parole?
Yes
No
Do you need help with recovering from Opioid(s) and/or drug and alcohol?
*
Yes
No
How did you hear about us ?
Referral
Search Engine/Web
Social Media
Word of mouth
Submit
Should be Empty: