Homeless Shelter Services Needs Assessment
Client Information
Name
Age
Gender
Female
Male
Non-Binary
Other
Prefer Not to Say
Contact Information
Current Situation
Current Living Situation
Street
Shelter
Vehicle
Transitional Housing
Other
Duration of Homelessness (in months)
Household Composition (children, partner, etc.)
Immediate Needs
Food
Clothing
Shelter
Hygiene
Medical Care
Other
If Other, please specify
Health & Well-Being
Are there any physical or mental health conditions we should be aware of?
Are you currently taking any medications?
Long-Term Needs
Permanent Housing
Employment
Education/Training
Legal Assistance
Counseling
Other
If Other, please specify
Comments / Additional Information