Client Intake Form
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1
2NEIGHBORHOOD HOUSE, INC.
A HUD-Approved Counseling Agency & Affiliate of HomeFree USA
CLIENT INTAKE FORM
Date: ____/____/________
Applicant ID: ____ ____
DEMOGRAPHIC INFORMATION
CLIENT
CO-CLIENT
___________________________________________________
___________________________________________________
First
Middle
Last
First
Middle
Last
___________________________________________
___________________________________________
Street Address
Street Address
_________________________
______
_____________
_____ yr(s)
_________________________
______
_____________
_____ yr(s)
City
State
Zip
Lived Here
City
State
Zip
Lived Here
(____) _____-________
(____) ____-_______
(____) _____-________
(____) ____-_______
Home Phone
Work Phone
Home Phone
Work Phone
(____) _____-________
____________________________
(____) _____-________
____________________________
Cell Phone
Email Address
Cell Phone
Email Address
______-_____-________
_____/_____/________
______-_____-________
_____/_____/________
SSN #:
DOB
SSN #:
DOB
CIRCLE MOST ACCURATE CHOICES
CIRCLE MOST ACCURATE CHOICES
Gender:
Male or Female
Gender:
Male or Female
Handicapped:
Yes or No
Handicapped:
Yes or No
Veteran: Yes or No
Veteran: Yes or No
Citizenship: US Citizen
Perm Resident Alien
Non-Resident Alien
Citizenship: US Citizen
Perm Resident Alien
Non-Resident Alien
Marital Status: Single
Married
Divorced
Separated
Widowed
Marital Status: Single
Married
Divorced
Separated
Widowed
Hispanic/Latino Ethnicity: Yes or No
Hispanic/Latino Ethnicity: Yes or No
Race: (1) African American/Black
(2) American Indian/Alaskan Native
Race: (1) African American/Black
(2) American Indian/Alaskan Native
(3) Asian
(4) Native Hawaiian/Other Pacific Islander
(5) White
(3) Asian
(4) Native Hawaiian/Other Pacific Islander
(5) White
Multi- Race: (1) African American/Black & White
Multi- Race: (1) African American/Black & White
(2) American Indian/Alaskan Native & White
(2) American Indian/Alaskan Native & White
(3) Asian & White
(4) Other Multiple Race
(3) Asian & White
(4) Other Multiple Race
Household Type:
Married w/ children
Married w/o children
Other
Household Type:
Married w/ children
Married w/o children
Other
Female single parent
Male single parent
Single adult
Female single parent
Male single parent
Single adult
2 or more unrelated adults
2 or more unrelated adults
Total Family Size: __________
Number of dependents: __________
Total Family Size: __________
Number of dependents: __________
Age/Gender of dependents: _______, _______, _______, _______, _______
Ages of dependents: _______, _______, _______, _______, _______, _______
Are there non-dependents that will be living in the home?
Yes or No
Are there non-dependents that will be living in the home?
Yes or No
Highest Level of Education: ___________________________________
Highest Level of Education: ___________________________________
EMPLOYMENT INFORMATION
CLIENT
CO-CLIENT
_________________________________ (____) ____-______
_________________________________ (____) ____-______
Current Employer
Phone
Current Employer
Phone
___________________________________________
___________________________________________
Street Address
Street Address
____/____/____
____/____/____
_________________________
______
__________
_________________________
______
__________
City
State
Zip
Hire Date
City
State
Zip
Hire Date
______________________________
______________________________
Status:
PT or FT
Status:
PT or FT
Title
Title
I am paid: Hourly
Weekly
I am paid: Hourly
Weekly
Gross Income: $______________
Bi-weekly
Bi-monthly
Monthly
Gross Income: $______________
Bi-weekly
Bi-monthly
Monthly
Other Source of Income: __________________________ $___________/mo
Other Source of Income: __________________________ $___________/mo
Other Source of Income: __________________________ $___________/mo
Other Source of Income: __________________________ $___________/mo
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