CSS Intake and Barriers to Housing Stability Assessment
- 1. New Horizons Behavioral Health Community Support Services Barriers to Housing Stability and Intake Assessment Please complete the entire form and return to the staff member at the front desk. BASIC INFORMATION Name: ________________________________________________________________________ Date of Birth: _______________________ Today’s Date: ________________________ Phone Number: ______________________ Are you a veteran? YES NO Age: _______________ Gender: ________________ Race:__________________ CURRENT HOUSING ASSESSMENT Are you currently homeless (living on the street, in a shelter, in a hotel, or in a place not meant for habitation)? □ Yes □ No How many times have you been homeless in the past 12 months? _________________________ How many times have you been homeless in the past 3 years? ____________________________ Have you received an eviction notice or are in the process of being evicted? □ Yes □ No □ Unknown Where did you sleep last night? ____________________________________________________ Do you need temporary or permanent assistance to get or keep housing? □ Yes, temporary assistance □ Yes, permanent assistance □ No □ Unknown Please give a description of your current housing situation and needs: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
- 2. HEALTH AND PERSONAL ASSESSMENT Mental Health Do you have a diagnosis of a mental illness or been told that you do? □ Yes □ No □ Unknown If yes, please list your diagnosis: _____________________________________________ Do you have mental health issues that have caused you to lose your housing in the past? □ Yes □ No □ Unknown Do you have mental health issues that currently affect your ability to get housing? □ Yes □ No □ Unknown Are you currently in treatment for mental health (counseling, therapy, medication management)? □ Yes □ No □ Unknown Substance Use Has substance use (drugs and/or alcohol) caused you to lose your housing in the past? □ Yes □ No □ Unknown Does current substance use affect your ability to get housing? □ Yes □ No □ Unknown Are you currently in treatment for substance use? □ Yes □ No □ Unknown Physical Health Have your physical abilities or physical health ever caused you to lose your housing? □ Yes □ No □ Unknown Does your physical health or abilities currently affect your ability to get housing? □ Yes □ No □ Unknown Domestic Violence/Abuse Has domestic violence or abuse ever caused you to lose your housing in the past? □ Yes □ No □ Unknown Does domestic violence or abuse currently affect your ability to get housing? □ Yes □ No □ Unknown Family Composition Do you currently have any children under age 18 in your household? □ Yes □ No □ Unknown Do you have any children under age 18 that you expect will live with you when you obtain housing? □ Yes □ No □ Unknown
- 3. INCOME AND BENEFITS ASSESSMENT Do you have a job or receive wages for work? □ Yes □ No □ Unknown If yes, please list the amount you earn per month: _______________________________ Do you need assistance with finding new or additional employment? □ Yes □ No □ Unknown If yes, what type of employment are you looking for? ____________________________ Are you currently receiving Supplemental Security (SSI) or Disability (SSDI) income? □ Yes □ No □ Ineligible □ Unknown If yes, please list the amount you receive per month: _____________________________ Are you currently receiving TANF? □ Yes □ No □ Ineligible □ Unknown If yes, please list the amount you receive per month: _____________________________ Are you currently receiving child support? □ Yes □ No □ Ineligible □ Unknown If yes, please list the amount you receive per month: _____________________________ Are you currently receiving assistance from the public housing authority? □ Yes □ No □ Ineligible □ Unknown If yes, please list the amount you receive per month: _____________________________ Are you currently receiving food stamps? □ Yes □ No □ Ineligible □ Unknown If yes, please list the amount you receive per month: _____________________________ Are you currently receiving health insurance? □ Yes □ No □ Ineligible □ Unknown If yes, please list the amount you receive per month: _____________________________ Do you need assistance applying for any of the benefits listed above? □ Yes □ No □ Unknown If yes, please list the benefits you need assistance with: ___________________________ If you are living in a house or apartment, what percent of income do you spend on housing (rent/mortgage AND utilities)? □ 35% or less □ 36-50% □ 51-65% □ 66-80% □ 80% or more □ Unknown If you are not living in your own house or apartment, how much money can you spend on housing (rent/mortgage AND utilities) each month? □ $0 □ $1-100 □ $101-200 □ $201-300 □ $301-400 □ $401-500 □ $501-600 □ $601-700 □ $701-800 □ more than $801 □ Unknown
- 4. HOUSING BARRIERS ASSESSMENT Rental History Have you ever had a lease for an apartment/home or utilities in your name? Check all that apply. □ Yes, a lease □ Yes, utilities □ No □ Unknown How many times have you been evicted from housing? □ 0 □ 1 □ 2-3 □ 4-9 □ 10 or more Would a prior landlord(s) give you a bad reference? □ Yes □ No □ Unknown Credit History Do you have unpaid rent or utility bills in your name? □ Yes □ No □ Unknown If yes, please list the unpaid amount(s) here: ____________________________________ Do you have a credit history? □ Yes □ No □ Unknown Do you have poor credit? □ Yes □ No □ Unknown Criminal History Have you ever been convicted of one or more misdemeanors? □ Yes □ No □ Unknown Have you ever been convicted of a felony? □ Yes □ No □ Unknown If yes, did the felony involve drugs, weapons, or a sex crime? □ Yes □ No □ Unknown Are you currently on probation? □ Yes □ No If yes, what is the date your probation expires? __________________________________ Is there anything not mentioned in this assessment that you need assistance with? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Thank you for completing this intake assessment. Please give this form to the staff member at the front desk. One of our intake staff will speak with you shortly.