Client intake form Name * First Name Last Name Client's Gender * Male Female Client's Race * African American Caucasian Hispanic Asian American Indian/Native American Other Date Of Birth * MM DD YYYY Client's Phone Number * Do we have permission to send text messages to the phone number? * Yes No Client's Email * Housing Preference * Shared Space Private Room How will the client pay for housing? * SSI/SSDI (self-pay) Retirement Organization Pay Other: What is the client's monthly income? If none, please type "None" Move-In Date * MM DD YYYY Does the client have a mental illness? If none, please type "none." If "yes" please describe. * Does the client have any other disabilities? If so, please describe. * Does the client require handicap accessibility? * Yes No Representative's Name * Is the client an ex-offender? * Yes No Is the client currently on probation or parole? * Yes No Does the client need help with alcohol or substance abuse recovery? * Yes No Does the client need case management services? * Health Insurance Retirement SSI/SSDI Job Placement Transportation Day Program Life Skills Group Group Therapy Individual Therapy Cellphone/Tablet Clothing Donations Thank you!
