Intake Form

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

City you are from *

For how long have you lived in that city? *

Approved For? *

Intake Form Date *

Stairs Yes or No? *

Do you have pets? *

How many pets and their breed? *

Is it a certified service dog? *

Status *

Vet

Felony

Domestic Violence

Do you have any Misdemeanors? If Yes, please list *

Sponsor Name *

Sponsor Contact *

Amount Sponsored *

Property Location/Room & Date *

Gross Income (monthly) *

Net Income (monthly) *

Please list your monthly bills and how much they are *

First Name *

Middle Name *

Last Name *

Age *

DOB *

Gender *

Male

Female

Other Names *

Phone *

Email *

Message Phone *

Spouse Name *

Age & DOB *

Spouse Gender

Spouse Number

Referred by

Name & Agency

Phone # Agency

Current City & How Long: Murrieta (Address/Street)

Current City & How Long: Wildomar (Address/Street)

Additional Cities

Last City of Permanent Residence & How Long *

Where have you been living? *

Other

How long have you been homeless? *

Eviction? *

Due To *

Homeless Before *

Where? *

How Long? *

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

What city is your family in? *

Marital Status *

Ethnicity

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

Are children currently with you *

Do you have legal custody of your children *

If no, explain

Are they attending school (Y/N) What City if Yes? *

Any medical issues or currently contagious *

Any prescription *

Lock Box *

Are you able to care for yourself *

Yes

Do you need help with (check all that aply) *

Willing to take a drug test *

Past or present addictions *

If yes, what addictions? *

Clean/sober how long? *

HIV/AIDs *

TB *

Pregnant (Y/N) Due date *

Any diagnosed mental condition? *

PTSD? *

Driver License *

ID Card *

No. & State *

Do you have transportation *

Employed *

Where & City *

Employment is *

Hourly Rate $, hours per week *

Benefits *

Pay period *

Method of payment *

Paydays *

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

When did it start? *

When does it end? *

Reason for unemployment *

High school diploma (Y/N) & Year *

GED (Y/N) & Year *

College (Y/N) & Year *

Special training? *

Reading/Writing ability *

Sanction/why *

Have you applied for public assistance? *

Received or applied for General Relief? *

Amount

Source of income? *

Amount of child support *

Total income *

Monthly Financial Obligation that are currently paid *

Total Bills *

Total obligations *

Balance $ *

US Citizen (Y/N) *

Veteran (Y/N) Branch? *

Discharge? Hon/DisHon *

Permanent Resident Alien (Y/N) *

Felony (Y/N) *

If yes, what is it for?

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

Gang Affiliation (Y/N) Affiliation Name *

Parole (Y/N) *

Formal Probation (Y/N) *

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

Have you been in this program before (Y/N), When, Where *

Willing to share a room? *

When do you have to move out? *

How much money do you have to move? *

Next paycheck date? *

Do you have a place to stay tonight? *

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

Please upload a picture of your ID or Drivers License below *

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