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?:---YesNo If so, when is their due date?: Client is currently at:---ShelterTreatment ProgramFamily/FriendOther How long has the client been there?: Name & Address of current location: Client is applying to:---Residence ProgramApartment Program Is the client currently in a substance abuse program?:---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?:---YesNo If in treatment, where?: Other services/agencies the client is involved with: Does the client have a source of income?:---YesNo If yes, list source and amount: If no income, has the client applied?:---YesNo If yes, where?: The person completing this form is:---The ClientFriend/Family MemberProfessional Working With Client Name: Phone Number: Agency Name, if applicable: Comments: Please enter the characters above: Please leave this field empty.
