Supported Housing Intake Form
Please fill out the intake form so we can better understand your needs and provide housing support that fits your situation.
Client Full Name:
*
First Name
Last Name
Client Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is the current City & State your living in?
*
Gender:
*
Male
Female
Race:
*
Black or African American
White or Caucasian
Hispanic or Latino
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
Other
Date of Birth:
*
Do you have children who need to be placed with you? If yes, please list how many children you have and their ages
*
Representative Name:
Representative Phone Number:
Representative Email address:
example@example.com
Emergency Contact Name & Number:
*
What is your current living situation?
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With Friends
With Family
In My Car
Shelter
Homeless
Shared Housing
Other
Do you have any disabilities or special needs? If yes, please describe your disabilities or special needs
*
Do you have a history of substance abuse?
*
Yes
No
Have you been convicted as a sex offender? If yes, please explain
*
Do you have any mental health conditions? If yes, please provide details
*
What is your current monthly income?
*
Employment
SSI/SSDI
Retirement
Organizational Funding
Other
How much is your monthly income? Please enter dollar amount
*
Do you have health insurance?
*
Yes
No
Other
When do you need to be placed?
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ASAP / Urgent
Within 30 Days = 1 Month or Less
Within 60 Days = 2 Months or Less
Within 90 Days = 3 Months or Less
Other
Is there a specific date that you need to be placed? If so, enter the date
*
Are you currently on probation or parole?
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Yes
No
How did you hear about us?
*
Referral
Social Media
Search Engine
Other
Is there anything else you would like us to know?
*
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