Intake -

Date: *
Referring Agency: *
Name: *

First

Last
Email Address: *
Phone number:
Date of Birth: *
Gender: *
Race: *
Marital Status: *

Single Married Divorced Separated Widowed
Home Address:
How long have you lived in Georgia?
Are you currently homeless?

Yes No
How long have you been homeless?
How many times have you been homeless in the past three years?
What type of income do you have?
What is your monthly income? *
Are you employed? *

Yes No
How long have you been employed?
Type of employment? *

Full-time Part-time
Employer name:
Job position:
Are you disabled? *

Yes No
What is your disability?
Do you receive any type of benefit such as? (Select all that apply): *

Food Stamps Medicare Medicaid SSI SDI Other
Are you a veteran?

Yes No
What is the highest level of education you have completed?
What type of assistance are you seeking? (Select all that apply): *

Clothing Counseling Employment Food Home Care Medical Rental Assistance Shelter Transportation Other

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