Homeless Individual Welfare Intake Assessment Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Non-binary
Prefer not to say
Other
Contact Number
Emergency Contact Name
Emergency Contact Number
Current Living Situation
Current Address/Location
Duration of Homelessness
Previous Housing Situation
Reason for Homelessness
Health & Wellbeing
Physical Health Concerns
Mental Health Concerns
Medications (if any)
Disabilities
Substance Use
Alcohol Use
Drug Use
Tobacco Use
Income & Employment
Current Income Source
Employment Status
Employed
Unemployed
Seeking work
Unable to work
Other
Skills/Qualifications
Support & Services Needed
Immediate Needs
Services Interested In
Other Comments