Nonprofit Shelter Intake Assessment Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Non-binary
Prefer not to say
Other
Contact Number
Email Address
Emergency Contact Name
Emergency Contact Phone
Relationship to Emergency Contact
Shelter Needs
Date of Intake
Reason for Seeking Shelter
Number of Family Members (if applicable)
Names & Ages of Other Occupants
Allergies or Dietary Restrictions
Any Pets Accompanying?
Yes
No
If yes, please specify
Medical Information
Medical Conditions (if any)
Medications Required
Accessibility Needs
Additional Notes
Anything else we should know?