Intake Form | Hyman House

YOUR NAME *

YOUR EMAIL *

YOUR PHONE NUMBER *

WHO ARE YOU APPLYING FOR?*

CLIENT'S FULL NAME *

CLIENT'S E-MAIL (IF AVAILABLE)

CLIENT'S BIRTH DATE *

WHAT IS THE CLIENT'S PRIMARY LANGUAGE? *

WHAT IS THE CLIENT'S MARITAL STATUS? *

CLIENT'S GENDER *

REASON FOR LEAVING

HAS THE CLIENT BEEN HOMELESS WITHIN THE LAST SIX MONTHS? YesNo

IS THE CLIENT AT RISK OF HOMELESSNESS? YesNo

HOW MANY OF THE LAST 30 DAYS HAS THE CLIENT BEEN IN A CONTROLLED ENVIRONMENT?

BEDROOM TYPE THE CLIENT IS INTERESTED IN? Private BedroomShared BedroomNo Preference

DOES THE CLIENT SMOKE? YesNo

DOES THE CLIENT HAVE A VIOLENT CRIMINAL RECORD? IF YES, EXPLAIN

IF YES - ENTER PROBATION OR PAROLE OFFICER'S NAME

IS THE CLIENT ON PROBATION OR PAROLE?

IF YES - ENTER PROBATION OR PAROLE OFFICER'S NAME

ENTER THE PROBATION / PAROLE OFFICER'S PHONE NUMBER IF APPLICABLE

DOES THE CLIENT HAVE A PENDING COURT CASE?

IS THE CLIENT DRUG FREE & SOBER?

IS THE CLIENT ON PRESCRIPTION MEDICATION?

DOES THE CLIENT HAVE MEDICAID?

CLIENT'S EMPLOYMENT STATUS Employed full-timeUnemployed - looking for workEmployed part-timeNot in labor force

HIGHEST GRADE COMPLETED

WHICH BEST DESCRIBES THE CLIENT'S MONTHLY INCOME?

WHAT IS THE CLIENT'S FUNDING SOURCE?

IF OTHER INCOME SOURCE - PLEASE EXPLAIN

NUMBER OF MINORS DEPENDENT ON INCOME?

DOES THE CLIENT RECEIVE STATE FOOD ASSISTANCE?

IS THE CLIENT WORKING WITH AN AGENCY, CASE MANAGER, OR SPONSOR?*

IF SO,WHAT IS THEIR PHONE NUMBER OR CONTACT INFO?*

ARE YOU INTERESTED IN MAINTAINING A SOBER LIFESTYLE? YesNoNot SureN/A (not applicable)

WHAT DO YOU THINK IS THE CLIENT'S BIGGEST OR MOST CHALLENGING ISSUE?

WHAT SPECIFIC ASSISTANCE OR SUPPORT WOULD BEST HELP THE CLIENT REACH THEIR GOALS?

IS THERE ANYTHING ELSE YOU WOULD LIKE TO TELL US ABOUT YOURSELF OR THE CLIENT?

WHEN WOULD THE CLIENT NEED TO MOVE IN?

CITY OF PREFERENCE (WEST VIRGINIA):

IF OTHER - ENTER CITY BELOW

ANY OTHER COMMENTS OR QUESTIONS?