Initial Inquiry Form

Client Name:

Date of Birth:

Phone Number:

Alternate Phone Number:

Why is the client homeless?:

How many children does the client have?:

What are the ages of the children who will be residing with the client?:

Is the client pregnant?:—Please choose an option—YesNo

If so, when is their due date?:

Client is currently at:—Please choose an option—ShelterTreatment ProgramFamily/FriendOther

How long has the client been there?:

Name & Address of current location:

Client is applying to:—Please choose an option—Residence ProgramApartment Program

Is the client currently in a substance abuse program?:—Please choose an option—YesNo

Length of sobriety/clean time (client must have at least 30 days):

If in a program, where?:

Is the client in treatment for mental health issues?:—Please choose an option—YesNo

If in treatment, where?:

Other services/agencies the client is involved with:

Does the client have a source of income?:—Please choose an option—YesNo

If yes, list source and amount:

If no income, has the client applied?:—Please choose an option—YesNo

If yes, where?:

The person completing this form is:—Please choose an option—The ClientFriend/Family MemberProfessional Working With Client

Name:

Phone Number:

Agency Name, if applicable:

Comments:

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