Intake Form for Chronically Homeless Individuals
Personal Information
First Name
Last Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Phone Number
Email
Current Location / Address
Emergency Contact (Name & Phone)
Homelessness History
How long have you been homeless?
Number of Episodes of Homelessness in the Past 3 Years
Where have you stayed while homeless? (Check all that apply)
Shelter
Streets
Car
Other
Last Stable Address (if known)
Health & Wellness
Medical Conditions
Mental Health History
Substance Use
Disabilities
Income & Benefits
Source(s) of Income
Benefits Currently Receiving (SSI, SSDI, SNAP, etc.)
Additional Information
What services do you need most right now?
Comments or Notes