EVMC Prescreen

PRESCREEN

East Valley Men's Center
A New Leaf's homeless shelters are a critical resource for those experiencing the housing crisis that is devastating our community.
- Our shelters provide everything, including: safety, basic needs, and comprehensive services that support vulnerable families and individuals in Arizona.
- To access Centralized Services, call: 877-211-8661 for emergency placement at a shelter.
- To access The Family Housing Hub, call: 602-595-8700. Families will discuss shelter needs and be placed on the service priority list for shelter services.
IMPORTANT NOTE: YOU MUST BE CURRENTLY HOMELESS IN THE PHOENIX METROPOLITAN AREA TO APPLY FOR A SHELTER BED
NOTICE: Failure to disclose or falsification of any information will be grounds for dismissal.
Who referred you to our program?

CBI NavigatorCity of Mesa - Off The Streets ProgramCity of Tempe - Hope OutreachA New Leaf - Gem Reentry ProgramCircle the CityGEM ProgramMesa Community CourtOther
Referral Contact Name
Referral Contact Email
example@example.com
Referral Contact Phone Number
Please enter a valid phone number.
Date*

MonthDayYear
Name*

First NameMiddle NameLast Name
Contact Phone Number*
Email*
Can we leave a message?*

YesNo
Date of Birth*

MonthDayYear
Have you stayed with us before?*

YesNo
Are you currently homeless?*

YesNo
If yes, how long ago?*
Are you a veteran?*

YesNo
Are you Disabled?*

YesNo
Where was your last permanent/long term residence located?*
What city & zip code are you currently located?*
Are you working with a CBI Outreach Team?*

YesNo
Do you feel like harming yourself or others?*

YesNo
If yes, please contact a Crisis Team at: 602-222-9444
Do you use any medical equipment that requires the use of an electrical outlet?*

YesNo
If yes, please explain*

Are you able to perform the following daily living skills without assistance?*

	Yes	No
Eating: Able to feed oneself
Bathing: Able to shower, brush teeth, and groom
Getting Dressed: Able to dress and undress
Mobility: Able to sit, stand, and walk
Continence: Able to control Bladder and Bowel functions
Toileting: Able to get to and from the toilet and clean oneself
Understand simple instructions/directives (in any written/spoken lang)

Do you have a Criminal History?*

YesNo
Are you required to Register on the Sex Offender Registry?*

YesNo
If yes, please explain criminal history (What, Where, Date & Year):*
Felonies or Misdemeanors. If Probation Violation, ID original crime
Do any of your charges include the use of a deadly weapon, violence, or kidnapping?*

YesNo
Do you have a Probation, Parole, or Surveillance Officer?*

YesNo
Are you working at this time?*

YesNo
If yes, what type?*

Part TimeFull TimeTemporarySeasonal
Last time worked*
Month/Year
Company Name*
Previous Employer
Occupation*
Current Occupation or Last Occupation
Monthly Income*
Do you have a vehicle?*

YesNo
If yes, proof of registration and insurance will be required at intake to park your vehicle on A New Leaf property
Upload a copy or take a picture (with your phone) of your registration and insurance information. You can also bring a physical copy with you to intake if you prefer.

Registration and Insurance Information
Cancelof
Please review and check to acknowledge the following items: *
EVMC provides a kit with basic essentials and the following information allows us to prepare this kit prior to your arrival.
Shirt Size*
Small up to 4X
Pants Size*
Small up to 4X
Race*
Ethnicity*
Anything else you would like us to know about you?
Questions about how to answer prescreening?

Please give us a call:

480-610-6722

ONLY MONDAY-FRIDAY 8AM-5PM

NO WEEKEND INTAKES AT THIS TIME
Should be Empty:

PRESCREEN