Family Shelter Intake Interview
General Information
Family Name
Date
Primary Contact Name
Phone Number
Email
Number of family members
Relationship to Head of Family
Family Members
List all family members (Name, Age, Gender, Relationship):
Housing History
Previous Address
Reason for seeking shelter
Has the family used shelter services before?
Yes
No
If yes, when and where?
Additional Needs
Medical needs or disabilities
Dietary restrictions
Transportation needs
Other special considerations
Interviewer Notes