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Client Information

Birthday
Month
Day
Year

Gender & Identity

Single choice
Male
Female
Non-Binary
Prefer not to say

Representative

Representative's role

Single choice
Case Manager
Parole Officer
Probation Officer
Social Worker
Family Member
Friend
Self
Other

Rep's Organization

Do we have permission to text and leave a message on the number provided?

Single choice
Yes
No

Demographics

Single choice
Caucasian
Black or African American
Hispanic
Asian
American Indian
Pacific Islander

Client's Current Living Situation 

Single choice
Living with a friend
Living in a car
Living in a shelter
Living on the streets
Temporary shelter
Incarcerated
Hospital/Facility
Shared housing/Group Home
Other

What type of room does the client prefer

Single choice
Single Room
Shared Room
It Doesn’t Matter

When does client need to be placed?

How will the client pay?

Single choice
SSI/SSDI
Retirement
Voucher
Organization Funding
Job
Other

How much do you receive? If NONE, please type NONE

Does the client suffer from mental illness?

Single choice
Yes
No

 Please list all diagnoses, if applicable

Please list all diagnoses, if applicable.

Are you disabled?

Single choice
Yes
No

List Disabilities

Does the client require a handicapped living environment?

Single choice
Yes
No

Is the client an ex-offender?

Single choice
Yes
No

Have you ever been convicted as a sex offender?

Single choice
Yes
No
With 1000 feet restriction
Without 1000-feet restriction

Your answer to this question does not disqualify you from our program/services.

Are you currently on probation or parole?

Single choice
Yes
No

Do you need help from opioids and or other drugs and alcohol?

Single choice
Yes
No

Will the client have children living with them? Please list ages

Single choice
Yes
No

Please list ages

Select all of the services you are requesting

Multi choice

How did you hear about us?

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