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Referring Agency
Agency Name:       Phone Number:   
Referred By:       Extension:   
Address:       Email:   
City, State Zip:   
Services Requested:   

Client Information
Full Name:       Phone:   
Gender:  (Choose One)    Male Female   Cell:   
SSN#:       Email:   
Address:       D.O.B.:   
City, State Zip:       Age:   
Source of Income:       Monthly Amount:   
Food Stamps:    No Yes   Monthly Amount:   
Military Service:    No Yes   Type of Discharge:   

Parent / Guardian:   
Relationship       Phone:   

Emergency Contact:   
Relationship:       Phone:   

History of Homelessness
Current Living Conditions:       How Long:   
Length of Homelessness:   
Number of times Homeless in the past 3 years:   

Mental Health History
Mental Health Diagnosis   
Present Treatment for Mental Health (agency and location) Medications / Dosage   
Recent hospitalizations  (within the past year)    No Yes,date and reason:
Doctor/Therapist Name:       Phone:   

Disability Health History
Disability Health Diagnosis:   
Disability Certification Statement Attached?  No    Yes
Present Treatment for Mental Health (agency and location) Medications / Dosage   
Recent hospitalizations  (within the past year)    No Yes,date and reason:
Doctor/Therapist Name:       Phone:   

Medical Information
Medicaid: Applied For:  (check one)    No Yes Accepted Denied
                  Receiving:  (check one)    No Yes, Number:
SSI:          Applied For:  (check one)    No Yes Accepted Denied
                  Receiving:  (check one)    No Yes, Number:
SSDI:        Applied For:  (check one)    No Yes Accepted Denied
Insurance: (name of provider)   
Primary Care Physician   
Address:   
Medical Conditions: (including allergies)   
Recent Hospitalizations:   (within the past year)    No Yes, date and reason
Smoke Cigarettes:   (check one)    No Yes

Substance Abuse History
How often does the client use alcohol?   
How often does the client use non-prescribed controlled substances:   
Has there been use of controlled substance within the past year?  (check one)    No Yes Unknown
Drugs of Choice:   
Rehab Agency:   
Address:   
Counselor:   
Past treatment (inpatient or outpatient) for substance abuse:   

Forensic History
Does client have any charges or convictions related to Sex Abuse?    No Yes
Does client have any Felony Convictions?    No Yes
Is client currently on Probation or Parole?    No Yes
Has client ever been incarcerated for more than two (2) years?    No Yes
Does client have any pending Legal Charges?    No Yes

Living Skills
Housing History and Patterns: (Including timelines for homelessness if possible)   
Activities of Life: (Hygiene, Housekeeping, Budgeting, Etc.)   
Other Comments or Concerns: