Client Intake Form

  • Individual Housing Intake Form

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  • Date of Birth *
     - -
  • Format: (000) 000-0000.
  • Do we have permission to send a text message to the phone number provided? *
  • Client's Gender*
  • Current Living Situation: *

  • Explain your situation.

  • Housing Preference: *
  • How will the client pay for housing? *
  • Move-In-Date
     - -
  • Does the client have a mental illness? If yes, please describe below.*
  • Does the client have any other disabilities? If yes, please describe in the section below.*
  • Does the client require handicap accessibility? If so, please describe in the section below:*

  • This is a fill in the field. Please add appropriate fields and text.

  • Is the client an ex-offender? *
  • Is this client a sex offender? *
  • Is the client currently on probation or parole? *
  • Does the client need help with alcohol or substance abuse recovery? *
  • Does the client need case management services? Please Check All That Apply.*
  • How did you hear about Georgia Mission Management?
  • Do you have a child/children that will be living with you?
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