Email * Client's Gender * Male Women Transgender Client's Name * First Name Last Name Representatives Name * Rep's Organization ( ex: United Way, VA, ect) * Client's Phone * Country (###) ### #### Do we have permission to text/leave a message on the number provided? * Yes No Race * Caucasian African American Hispanic Asian American Indian/Native American Islander Date of Birth * MM DD YYYY Client's Current Living Situation * Living w/ a friend Living in a car Living in a shelter Living on the street Incarcerated Hospital/Facility Shared Housing/Group Home What type of room does the client prefer * Shared Private When does client need to be placed? * MM DD YYYY How will the client pay? * SSI/SSDI Retirement Voucher Organization Funding Job Other How much income do you receive monthly? If none please type NONE How much income do you receive monthly? If none please type NONE * Does the client suffer from mental illness * Yes No If answered yes, list mental diagnoses * List disability (s) Does client require a Handicap Accessible Living Environment Yes No Is the client an ex-offender * Yes No Have you been convicted as a Sex Offender?( Your answer to this question does not disqualify you from our program and services) Yes No with 1000ft restriction without 1000ft restriction Are you currently on Probation or Parole? * Yes No Do you need help with recovering from Opioid)s) and /or other drugs and alcohol? yes no Will the client have children living with them? ( Please list ages) * Select all of the services you are requesting * Transportation Assistance Job Placement Apply for SNAP benefits Apply for SSI/SSDI Organizational Payee Health Insurance Enrollment Clothing Donation Cellphone/Tablet Assistance Group Therapy Day Program Life Skills/Recovery Groups How did you hear about us? * Referral Search Engine/Web Social Media Word of Mouth Thank you! Housing Intake Assessment
