Intake Form Pre-Intake sheet Name Current Address Phone Number Finance available Follow up Preferred Gender Pronoun Reason for homelessness Number of People Interview Date & Time Move In Date INTAKE INTERVIEW Client Name Phone Intake Date Date of Birth Current Place of Residence Children (Name & Age) Drug History Sobriety Date Drug of choice Are you willing to participate in a drug treatment program YesNo Criminal History Are you willing to participate in our outreach case management program YesNo Client Signature Staff Witness Date Date INQUIRY FOR SERVICES Date Last 4 Digits of Client SNN # Current Living Situation What type of services are you in need of from Momma’s House/ Case management Services currently received from other Providers Concerns and questions raised by applicant, family, residential service provider or service coordinator
