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Intake
Intake Form
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
What service are you interested in?
Background
Race/Ethnicity
(Required)
African Refugee
Asian
African American
Latin/Hispanic
Middle Eastern
Pacific Islander
Native Hawaiian
Native American/Alaskan Native
Slavic/Russian
White/Caucasian
Other
I decline to answer
What is your highest level of education
(Required)
No Schooling Completed
Kindergarten to 4th Grade
5th or 6th Grade
7th or 8th Grade
9th Grade
10th Grade
11th Grade
12th Grade/No Diploma
High School w/ Diploma
GED
Post-Secondary School
I decline to answer
Do you have any health conditions?
(Required)
Mental Health Issues
Physical Disability
Developmental Disability
HIV/AIDS
Yes, but I decline to disclose details
No, None
Are You Married?
(Required)
Yes
No
History
Do you have any current or past substance use?
(Required)
Drug use
Alcohol use
Drug and alchohol use
None
Are you or have you ever been a survivor of domestic violence?
(Required)
Yes
No
Are you currently fleeing a domestic violence situation?
(Required)
Yes
No
Are you on probation or parole?
(Required)
Yes
No
If you are currently homeless, have you been homeless for 12 or more months?
(Required)
Yes
No
Have you been homeless off and on 4 or more times in the last 3 years?
(Required)
Yes
No
Household Details
Are you the head of your household?
(Required)
Yes
No
How many adults are in your household (include yourself)?
(Required)
How many children do you have?
(Required)
How many children currently live with you?
(Required)
What is your current living situation?
(Required)
Homeless
Shelter
Temporary Housing
Rental
Transitional Housing
Jail/prison
Substance Abuse Treatment Facility
Living with family
How long have you been where you are currently living?
(Required)
1 night or less
2 to 6 nights
1 to 4 weeks
1 to 2 months
3 to 11 months
12 months or longer
What barriers do you have for housing?
I am under the age of 25 and have no prior rental history.
(Required)
Yes
No
I have a large gap in my rental history.
(Required)
Yes
No
I owe a previous landlord money.
(Required)
Yes
No
I have bad landlord references.
(Required)
Yes
No
I am 16-27 and was under the jurisdiction of the juvenile court in the past 10 years.
(Required)
Yes
No
Are you paying more than 1/3 of your monthly income towards rent/mortgage?
(Required)
Yes
No
Are you currently being asked to leave your current residence and lack the resources to obtain other long-term housing?
(Required)
Yes
No
Will you have Section 8 or rental assistance when you look for your new place?
(Required)
Yes
No
Are you on any Housing Authority waitlist(s)?
(Required)
Yes
No
Income – Please enter your income from the following sources:
Earned Income/ Wages $
(Required)
Pension $
(Required)
TANF/AFDC $
(Required)
Worker's Comp. $
(Required)
Child Support $
(Required)
WIC benefits $
(Required)
Unemployment $
(Required)
SNAP/Food Stamps $
(Required)
SSI/SSDI $
(Required)
Non-cash benefits $
(Required)
Other: $
(Required)