Intake Assessment

Intake Assessment

Steps toward solutions
Client Information
Client Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Sex at Birth
Race

Other
Do you have children that are joining the program with you?
Preferred Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail Address
example@example.com
Emergency Contact Full Name

First NameLast Name
Emergency Contact Relationship to Client
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Representative Name (if applicable)

First NameLast Name
Representative Organization (if applicable)
Current Living Situation
Select all that apply
Brief Summary of Reason for Housing Need
If yes, how many children are joining?
Tell me about yourself
Referral Source (if applicable)
Do you have a valid ID/Driver’s License?
Do you have a copy of your birth certificate?
Do you have a copy of your social security card?
Medical History
Please list any medical history including allergies
Please list any medication(s) you currently take
Do you have any mental health diagnosis?
Do you have any mental health diagnosis that are untreated?
Are you recovering from drug or alcohol addiction?
Legal Background
Do you have a criminal record?
Are you currently on probation or parole?
Are you a registered sex offender?
Income Information
Do you have a source of income?
What is your source of income?
If other, please explain:
Monthly income amount (if any):
Housing Preferences
Will you require any wheelchair accessible features, mobility assistance, or other accommodations?
Are you comfortable living in a shared environment?
Preferred room type
Do you require short-term or long-term housing?
Do you require first-floor housing or have restrictions with stairs?
Can you live independently and manage your Activities of Daily Living (ADL) without assistance?
Do you currently have or will need a home health care provider or outside support service?
Independent Living & Functionality Acknowledgment
This program provides independent living housing only and does not provide medical or personal care services. Residents are responsible for arranging any required medical or personal care outside of this housing program.
I understand and agree that this program provides housing only.
If selected for the program do you consent to fully comply with all program policies and house rules at all times?
Select all of the services you are requesting:
Desired move in date

MonthDayYear
Date
I certify that the above information is true to the best of my knowledge. I understand that this intake does not guarantee placement, and my application will be reviewed by staff.
Signature (print full name)

First NameLast Name
Should be Empty:

Intake Assessment

Client Information

Current Living Situation

Medical History

Legal Background

Income Information

Housing Preferences

Independent Living & Functionality Acknowledgment