Consolidated Client Intake and Assessment Form

Housing Intake - Consolidated Client Intake and Assessment Form

Section 1: Personal Information

Participant 1:

First Name

Last Name

Date of Birth

Age

Gender

Race

Hispanic

Phone Number

Email Address

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Homeless?

Yes

If yes, Length

Where do you sleep most nights?

Are you a veteran?

Yes

Are you disabled?

Yes

Health Insurance?

Yes

Insurance Carrier:

Marital Status

Participant 2:

First Name

Last Name

Date of Birth

Age

Gender

Race

Hispanic

Phone Number

Email Address

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Homeless?

Yes

If yes, Length

Where do you sleep most nights?

Are you a veteran?

Yes

Are you disabled?

Yes

Health Insurance?

Yes

Insurance Carrier:

Marital Status

Local Emergency Contact:

First Name

Last Name

Relationship to Participant

Phone Number

Family Support:

Do you have a support system, and who would you consider as part of your support system?

Name	Relationship

Section 2: Household Members

Please list all other adults in the household.

Click on the plus icon (+) to add more or the minus icon (-) to remove fields.

Name (Last Name, First Name)

Relationship

Date of Birth

Sex

Race

Hispanic

Veteran

Insurance

Monthly Income

Please list all children under 18 who reside in the home.

Click on the plus icon (+) to add more or the minus icon (-) to remove fields.

Name (Last Name, First Name)

Relationship

Date Of Birth

School

Grade

Sex

Race

Hispanic

Disability

Insurance

Custody

Consolidated Client Intake and Assessment Form