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Intake Form

Todays Date:____/_____/______________

First Name: ___________________________________ Middle Name: _________________________

Last Name: _____________________________________________ Suffix:______________________

Date of Birth: ____/____/________ or: Dont know Refused

Gender: Male Female Transgender Male to Female Transgender Female to Male Other
Dont Know Refused
Ethnicity: Non-Hispanic/Latino Hispanic/Latino Dont Know Refused
Race (choose all that apply)
American Indian or Alaska Native Black or African American White Asian
Native Hawaiian or Other Pacific Islander Dont Know Refused Other
Marital Status
Married Divorced Widowed Common Law Domestic Partner Separated Single
Military Background
Served/Serving U.S. Military (veteran): No Yes Dont Know Refused
Disabling Condition (For All Individuals and Family Members)
Do you have a disabling condition No Yes Dont Know Refused

Primary Address __________________________ City ____________ State _____ Zip Code__________
Phone Number _____________________ Cell _____________________ Work _____________________
Email ____________________________________

Describe Your Situation

Literally Homeless (You are living in an emergency shelter, hospital or institution, transitional housing,
fleeing domestic violence situation, or living in places not meant for human habitation, such as cars, parks, sidewalks,
abandoned buildings, on the street)

Housed & at imminent risk of losing housing (You are being evicted, being discharged from hospital or institution,
or living in a condemned building; and do not have new housing identified and lack financial resources and support
networks to obtain appropriate housing or maintain current housing)

Housed & at risk of losing housing (You are housed or doubled up with friends or relatives and are at-risk of losing
housing due to high housing costs, conflict, or other conditions and lack the resources and support networks needed to
maintain or obtain housing. However, you are not in immediate danger of becoming homeless)

Stably Housed

Dont Know

Refused





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Where Did You Stay Last Night? (Choose one):
Emergency Shelter, including Hotel or Motel Paid for with an
Emergency Shelter Voucher. Migrant Shelter
Rental by Client, No Housing Subsidy
Foster Care Home or Foster Care Group Home Rental by Client with VASH Housing Subsidy
Hospital (Non-Psychiatric) Rental by Client with Other Housing Subsidy (Non-VASH)
Hotel or Motel Paid for without an Emergency Shelter Voucher Safe Haven
Jail or Prison Staying or Living in a Family Members Room, Apartment or
House
Juvenile Detention Staying or Living in a Friends Room, Apartment, or House
Owned by Client, No Housing Subsidy Substance Abuse Treatment Facility or Detox Center
Owned by Client, With Housing Subsidy Transitional Housing for Homeless Persons
Permanent Housing for Formerly Homeless Persons Dont Know
Place Not Meant for Habitation (Car or Other Vehicle, Abandoned
Building, Bus/Train/Subway Station/ Airport, Outside Anywhere,
Camping)
Refused
Psychiatric Hospital or Other Psychiatric Facility Other
_______________________________________________

How long have you stayed at the place you spent last night: (choose one):
1 week or less More than 3 months, but less than 1 year Dont Know
More than 1 week, less than 1 month 1 year or longer Refused
1 month to 3 months


Where Did You Stay Before Your Most Recent Location (where do you typically stay) (choose one):

Emergency Shelter, including Hotel or Motel Paid for with an
Emergency Shelter Voucher. Migrant Shelter
Rental by Client, No Housing Subsidy
Foster Care Home or Foster Care Group Home Rental by Client with VASH Housing Subsidy
Hospital (Non-Psychiatric) Rental by Client with Other Housing Subsidy (Non-VASH)
Hotel or Motel Paid for without an Emergency Shelter Voucher Safe Haven
Jail or Prison Staying or Living in a Family Members Room, Apartment or
House
Juvenile Detention Staying or Living in a Friends Room, Apartment, or House
Owned by Client, No Housing Subsidy Substance Abuse Treatment Facility or Detox Center
Owned by Client, With Housing Subsidy Transitional Housing for Homeless Persons
Permanent Housing for Formerly Homeless Persons Dont Know
Place Not Meant for Habitation (Car or Other Vehicle, Abandoned
Building, Bus/Train/Subway Station/ Airport, Outside Anywhere,
Camping)
Refused
Psychiatric Hospital or Other Psychiatric Facility Other
_______________________________________________

BENEFITS (For All Individuals and All Family Members)
Non-Cash Benefits (All Individuals and Family Members)
Non-Cash Benefit Received from any source in the last 30 days: Yes No Dont Know Refused
Yes No
Food Stamps or Money Benefits Card (Supplemental Nutrition Assistance Program (SNAP):

Food Stamps (or SNAP) Amount: $_______________
MEDICAID Health Insurance Program:

MEDICARE Health Insurance Program:

State Childrens Health Insurance Program:

Women, Infants and Children (WIC):

Veterans - VA Medical Services:

TANF Child Care Services:

TANF Transportation Services:

TANF (Other TANF-funded Services):

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Section 8, Public Housing, or Other Rental Assistance or Housing Vouchers:
(Through What Agency? ___________________________________________________)

Other Benefit Sources: (Through What Agency?)

EMPLOYMENT (for Adults (Age 18+) and Unaccompanied Minors)
Employed: Yes No Dont Know Refused Child is a Minor
I f Currently Working, How Many Hours Worked in the Past Week: __________________________________
Type of Work: Permanent Temporary Contract-Based Dont Know Refused
I f unemployed, are you looking for work? I f employed, are you looking for additional employment or increased hours at current job?
Yes No Dont Know Refused

Health Information
General Health I nformation (For All Individuals and All Family Members )
General Health Rating (choose one): Excellent Very Good Good Fair Poor Dont Know Refused
Currently Pregnant?: Yes No Dont Know Refused
If Yes, What Is The Due Date ?: (mm/dd/yyyy): ______/_______/___________
Health I nformation (For All Individuals and All Family Members )
Disabling Condition?
Yes No Dont Know Refused
Diagnosed HI V/AI DS:
Yes No Dont Know Refused
(If Yes) Currently Receiving Service or Treatment for this
Condition
Yes No Don't Know Refused
Substance Abuse Problem: Type of Substance Abuse Problem

Alcohol
Abuse
Drug
Abuse
Both Alcohol
and Drug Abuse
No


Don't Know Refused
Currently Receiving Service or Treatment?
Yes No Don't Know Refused
Mental Health Problems: Yes
No Don't Know Refused
(If Yes) Currently Receiving Service or Treatment?
Yes No Don't Know Refused
Physical Disability:
Yes No Dont Know Refused
(If Yes) Currently Receiving Service or Treatment?
Yes No Don't Know Refused
Developmental Disability:
Yes No Dont Know Refused
(If Yes) Currently Receiving Service or Treatment
Yes No Don't Know Refused
Chronic Health Condition:
Yes No Don't Know Refused
(If Yes) Currently Receiving Service or Treatment
Yes No Don't Know Refused