Intake Form Complete during first visit (~5 mins) 1. Name (Individual / Family) 2. How did you hear about us? -- Please select -- Friend/Family Another Agency Website/Internet Search Street Outreach Team Hospital/Healthcare Provider Other 3. What support do you hope to have at ReVive's Engagement Center? 4. Current Housing Status: a. Unstably housed Defined by following barriers: Risk of eviction Landlord issues DV issues Trouble paying rent Managing my home Disability affecting me from living safely / staying in my home Other b. Couch surfing c. In a emergency shelter d. Unsheltered (train, tent, abandoned building) e. None of the above 5. Past Housing Status: a. Have experienced homelessness or housing instability b. N/A Note: If yes to 4a or 5a → can enroll in SHP 6. CM-Identified Information (indicate if client or staff identified) Demographics: a. Race -- Please select -- American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander White Multiracial Other b. Ethnicity -- Please select -- Hispanic/Latino Non-Hispanic/Latino c. Language -- Please select -- English Spanish Other d. Gender -- Please select -- Female Male Transgender Non-binary Other e. Pronouns -- Please select -- She/Her He/Him They/Them Other f. Disability -- Please select -- Yes No g. Veteran -- Please select -- Yes No h. DOB or birth year i. Documentation needs for housing ID SS card Other j. Employment status / need -- Please select -- Sufficiently employed Underemployed Unemployed k. Income status / need -- Please select -- No income Low income Earned income On disability Note: If yes to 4e and 7k (has stable and sufficient income) → refer to Sharrise to explore other resources / not qualified for some onsite supports (e.g., laundry) Cancel Submit
