Intake Form

PROJECT T.O.U.C.H. Intake

1. Intake Form Date *

2. City you are from *

3. For how long have you lived in that city? *

Approved For (Office Use Only)

4.What city are you currently living in? *

5. If you chose Other, please list what city you currently live in.

6. Please detail how long you have lived there and include address or cross streets

7. Last City of Permanent Residence & How Long *

8. Where have you been living? *

9.Other Living Information

10. Have You Been In This Program Before (Y/N) *

11. Willing to share a room? *

12. Stairs Yes or No? *

13. Are you in a wheelchair or walker? *

14. Are You Able To Care For Yourself (Y/N) *

15. Do you need help with (check all that apply) *

16.Do you have pets? *

17. Felonies (Y/N) City, Year, Charges

18. Misdemeanors (Y/N), City, Year, Charges *

Status (Office Use Only)

Vet

Felony

Domestic Violence

19. Gang Affiliation (Y/N) Affiliation Name *

20. Parole (Y/N) *

21. Formal Probation (Y/N) *

22. Informal Probation (Y/N) How Long, Year Completed, Reason *

23.First Name *

24. Middle Name *

25. Last Name *

26. Age *

27. DOB *

28. Gender *

Male

Female

29. Other Names *

30. Phone *

31. Email *

32. Message Phone *

33. Age & DOB *

34. Driver License OR ID *

35. No. & State *

Please Upload a Copy of your ID or Drivers License

36. Do you have transportation *

37. US Citizen (Y/N) *

38. Permanent Resident Alien (Y/N) *

39. Ethnicity

40. Reading/Writing ability *

41. High school diploma (Y/N) & Year *

42. GED (Y/N) & Year *

43 .College (Y/N) & Year *

44. Special training? *

Attending School? *

If Yes, What City? *

45. Veteran (Y/N) Branch? *

46. Discharge? Hon/DisHon *

47. Marital Status *

48. Spouse Name *

49. Spouse Gender

50. Spouse Number

51. Referred by

52. Name & Agency

53. Phone # Agency

54. How long have you been homeless? *

55. Eviction? *

56. Due To *

57. Homeless Before *

58. Where? *

59. How Long? *

60. Do you have family/friends to HELP or SUPPORT you? *

61. What city is your family in? *

62. Children's Names (F&L), Age & DOB, F/M *

63. Are children currently with you *

64. Do you have legal custody of your children *

65. If no, explain

66. Other

67. Any medical issues or currently contagious *

68. Any prescription *

69. Lock Box *

70. Willing to take a drug test *

71. Past or present addictions *

72. If yes, what addictions? *

73. Clean/sober how long? *

74. HIV/AIDs *

75. TB *

76. Pregnant (Y/N) Due date *

77. Any diagnosed mental condition? *

78. PTSD? *

79. Employed *

80. Where & City *

81. Employment is *

82. Hourly Rate $, hours per week *

83. Benefits *

84. Pay period *

85. Method of payment *

86. Paydays *

87. Do you receive unemployment (Y/N) & Amount *

88. When did it start? *

89. When does it end? *

90. Reason for unemployment *

91. Have you applied for public assistance? *

92. Sanction/Denied Give reason why *

93. Received or applied for General Relief? *

94. Assistance Amount

95. Source of income? *

96. Amount of child support *

97. Total income *

Gross Monthly Income (Office Use Only)

98.Please list your monthly bills and how much they are *

99. Monthly Financial Obligation that are currently paid *

100. Total Bills *

101. Total obligations *

102. Balance $ *

103. When do you have to move out? *

104. How much money do you have to move? *

105. Next paycheck date? *

106. Do you have a place to stay tonight? *

107. In your own words, briefly explain how you became homeless: *