Supportive Housing Intake Assessment

Supportive Housing Intake

Please complete this form to help us understand your housing needs and eligibility for supportive housing services.
Full Legal Name

First NameLast Name
Client's Gender
Race
Date of Birth

MonthDayYear
Date
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?
Email Address
example@example.com
County of Last Residence
Current Address (if any)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Representative's Name
Rep's Organization (ex: United Way, VA, etc)
Representative's Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact (Name & Relationship)

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Identification & Documents (may be requested at intake)
Where did you stay most recently?

Other
Have you ever had an eviction?
If yes (optional):
Income Source(s)
Current Monthly Income (approx.)
Are you currently on Probation or Parole?
Any housing or shared-living restrictions?
If yes:
Any medical or mental health conditions staff should know in an emergency?
If yes (optional):
Currently prescribed medications?
Are you currently experiencing housing instability or homelessness?

Other
Client's Current Living Situation
What type of room does the client prefer
When does client need to be placed?
How will the client pay?
How much income do you receive monthly? If none please type NONE
Does the client suffer from mental illness?
If answered yes, list mental diagnoses
Are you disabled?
List disability(s)
Does client require a Handicap Accessible living environment?
Is the client an ex-offender?
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?
Will the client have children living with them? (Please list ages)
I understand this is a program participation arrangement, not a traditional lease or tenancy. I understand participation requires compliance with program rules, house expectations, and community standards.
Printed Name
Applicant Signature
Date

MonthDayYear
Date
Should be Empty: