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Supportive Housing Client Intake Form
Date of Intake
Referral Agency / Referrer
Participant Information :
Full Name:
DOB:
Age:
SSN (Last 4):
Phone:
Email Address:
Gender:
Male
Female
Non-binary
Prefer not to say
Emergency Contact:
Relationship
Phone:
Current Living Situation
Homeless
Couchsurfing
Transitional
Jail Release
Hospital
Other
Medical & Mental Health
Diagnoses:
Medications:
Allergies:
Substance Use History
Alcohol
Drugs
None
Details:
Legal Background
Parole/Probatio
Yes
No
PO Name/Phone:
Sex Offender
Yes
No
Income Information
SSI
SSDI
Employment
Other
Monthly Amount: $
Attach File
Housing Needs
Disability/Accommodation
Yes
No
Details:
Independent Living Acknowledgment
I understand I am responsible for my hygiene, medication, meals, transportation, and daily living
I understand this program does NOT provide medical or personal care.
Full Name
Date:
Send
