Name * First Name Last Name Email Phone * (###) ### #### Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * Female Male Date of Birth * MM DD YYYY Do you have an ID card? * Yes No Do you have a Social Security Card? * Yes No Social Security Number (if you don't have one, please put N/A) * Do you have a Drivers License? * Yes No Drivers License Number (if you don't have one, please put N/A) * When do you need housing? Immediate (< 2 weeks) 1 month 2 months 3 months What date do you need housing to start? * MM DD YYYY What organization is helping you (if none, please put N/A) * Emergency Contacts/Family or Friends - Names and Numbers (provide at least 2) * Income Status * Working Other If you checked Working, please list employer information If you checked Other, please explain Please tell us about any other income here Do you have a car? * Yes No Please list any prescription medications you are taking (if none, please put N/A) * Do you have any allergies (if none, please put N/A) * What are your goals and plans for this semester? * Why do you want to live at Solid Ground House? Why have you chosen this type of housing option? * What else should we know about you in order for us to better assist you? * Thank you! Client Intake Form
