Intake Form

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

1. Intake Form Date *

Approved For (Office Use Only)

2. What city are you currently living in? *

How long? *

3. Last City of Permanent Residence & How Long *

4. Where have you been living? *

5. Other Living Information

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

7. Willing to share a room? *

8. Stairs Yes or No? *

9. Wheelchair or walker? *

10. Are You Able To Care For Yourself (shower/cook) Y/N *

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

12. Do you have pets? *

13. Felonies (Y/N) City, Year, Charges *

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

Status (Office Use Only)

Vet

Felony

Domestic Violence

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

16. Parole (Y/N) *

17. Formal Probation (Y/N) *

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

19. First Name *

20. Middle Name *

21. Last Name *

22. Age *

23. DOB *

24. Gender *

Male

Female

25. Other Names *

26. Phone *

27. Email *

28. Message Phone *

29. Age & DOB *

30. Driver License OR ID *

No. & State *

Please Upload a Copy of your ID or Drivers License

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

31. Do you have transportation *

32. US Citizen (Y/N) *

33. Permanent Resident Alien (Y/N) *

34. Ethnicity

35. Reading/Writing ability *

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

37. GED (Y/N) & Year *

38 .College (Y/N) & Year *

39. Special training? *

Attending School? *

If Yes, What City? *

40. Veteran (Y/N) Branch? *

41. Discharge? Hon/DisHon *

42. Marital Status *

43. Spouse Name *

44. Spouse Gender

45. Spouse Number

46. Referred by

47. Name & Agency

48. Phone # Agency

49. How long have you been homeless? *

50. Eviction? *

51. Due To *

52. Homeless Before *

53. Where? *

54. How Long? *

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

56. What city is your family in? *

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

58. Are children currently with you *

59. Do you have legal custody of your children *

60. If no, explain

61. Other

62. Any medical issues or currently contagious *

63. Any prescription *

64. Lock Box *

65. Willing to take a drug test *

66. Past or present addictions *

67. If yes, what addictions? *

68. Clean/sober how long? *

69. HIV/AIDs *

70. TB *

71. Pregnant (Y/N) Due date *

72. Any diagnosed mental condition? *

73. PTSD? *

74. Employed *

75. Where & City *

76. Employment is *

77. Hourly Rate $, hours per week *

78. Benefits *

79. Pay period *

80. Method of payment *

81. Paydays *

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

83. When did it start? *

84. When does it end? *

85. Reason for unemployment *

86. Have you applied for public assistance? *

87. Sanction/Denied Give reason why *

88. Received or applied for General Relief? *

89. Assistance Amount

90. Source of income? *

91. Amount of child support *

92. Total income *

Gross Monthly Income (Office Use Only)

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

94. Monthly Financial Obligation that are currently paid *

95. Total Bills *

96. Total obligations *

97. Balance $ *

98. When do you have to move out? *

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

100. Next paycheck date? *

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

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