Intake Questions:

1. Name: 

2. D.O.B.

3. Where do you reside now.

Current Living Situation? Ex: living in car, hospital, homeless. shelter, living w/family or friend, etc. 

 Do you have a Case Manager?, 

Case Manager Name?Number?

5. Emergency Contact.

6. Do you have any Disabilities/Special Needs? If so please explain: 

7. Do you have any mental health conditions?

8. Do you have any health conditions? If so please explain: 

8b. Do you have any contagious conditions, ex TB or HIV?

8c. Do you have cough, fever, flu?

9. Is there a history of Substance Abuse? If yes, when was the last time used?       Drug of choice?

10. Are you a convicted Sex Offender? If so when were you Convicted?

11. Are you currently on Parole/Probation?

INCOME

1. Are you currently receiving any form of the following on a monthly basis?

A. SSI, B. SSDI, C. VA BENEFITS, D. PENSION, E. EMPLOYED, F. CHAARITY ASSISTANCE, G. OTHER

2. Please describe & provide amounts received on monthly basis:

3. Do you receive assistance with food? Will you need assistance w/food?

4. Do you have health insurance? Will you need assistance with obtaining health insurance?

5. When would you like to move in?

YOU MAY LEAVE A BRIEF COMMENT IN THE MESSAGE SECTION AS TO WHY YOU WOULD BE A GOOD FIT INTO THIS STRUCTURED ENVIRONMENT. 

THANK YOU FOR CONSIDERING US AS YOUR  NEW SAFE SPACE.

DON'T FORGET TH CHECK THE 'SEND ME A COPY' BOX !!