Homeless Youth Intake Application
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Transgender
Non-binary
Other
Prefer not to say
Contact Number
Email Address
Current Situation
Current Living Situation
Unsheltered (Street, Park, etc.)
Shelter
Transitional Housing
Couch Surfing
Other
Length of Time Homeless
Primary Reason for Homelessness
Education & Employment
Current Education Status
In School
Graduated
Dropped Out
GED
None
Current Employment Status
Employed Full-time
Employed Part-time
Unemployed
Looking for Work
Health & Support
Medical Conditions or Needs
Mental Health Concerns
Support Services Needed
Emergency Contact
Name
Relationship
Phone Number