863-453-8901 info@heartlandcoalitionforthehomeless.org

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Client Contact Intake Application

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First Name *

Last Name *

Gender *

Female
Male
Transgender
Non-binary
Other

Social Security Number: *

Date of Birth: *

Age: *

Phone *

Email *

I consent to provide any accurate/pertinent information needed for the enrollment processing regarding my request for rental assistance. *

Yes
No
Refuse

Questions

Who referred you to our agency? *

Which best describes your family dynamic? *

Single
Family without Minor Children
Family with Minor Children
Senior 55+
Head of Household with disability income

What is your current household size? *

Number of adults in your household, including yourself? *

Number of children in your household (under 18)? *

Please complete the information below for all family members living or will be in the household.

1. Full Name:

1. Date of Birth:

1. SSN:

1. Age:

2. Full Name:

2. Date of Birth:

2. SSN:

2. Age:

3. Full Name:

3. Date of Birth:

3. SSN:

3. Age:

4. Full Name:

4. Date of Birth:

4. SSN:

4. Age:

5. Full Name:

5. Date of Birth:

5. SSN:

5. Age:

6. Full Name:

6. Date of Birth:

6. SSN:

6. Age:

7. Full Name:

7. Date of Birth:

7. SSN:

7. Age:

What county are you located in? ? Please check only one. *

Desoto
Glades
Hardee
Hendry
Highlands
Okeechobee

Are you a Veteran? *

Yes
No

Were you affected by a disaster i.e., hurricane IAN? *

Yes
No

Does the head of the household have income? *

Yes
No

What is your household's total monthly income? *

Where did you sleep last night? *

Please fill out the below information.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

What service are you seeking? Please check only one. *

I am currently behind on my rent.
I am homeless and need help moving into a place I have found.
I need help with finding a shelter.

Please provide a detailed description of your current crisis: *

Head of Household Signature: *

Clear Signature

Head of Household Printed Name: *

Date: *

Section Divider

Phone *

Preferred Method of Communication *

Phone
Email

Contact Information-Times, Days *

Demographics/Race: *

American Indian
Asian or Asian American
Black, African American
Middle Eastern
Native
White

Demographics/Ethnicity: *

Hispanic
Not Hispanic

What type of assistance are you looking for? *

Past Due: Utility Assistance
Past Due: Rent or Mortgage
Housing Search and Placement
Future Payment: Rent or Mortgage
Future Payment: Utility Assistance
Other Services

Do you have a phone or way to be contacted? *

Yes
No

Do you have food to eat today? *

Yes
No

Section Divider

Do you have access to clean water? *

Yes
No

Do you have access to a restroom and hygiene supplies? *

Yes
No

Is anyone currently threatening to hurt or kill you, and/or loved ones, damage your belongings, and/or demand control of your whereabouts physically or technologically? *

Yes
No

Prior living situation (where did you sleep last night) Homeless Situation *

Vehicle or some place outside
Emergency Shelter
Hotel (being paid for by an organization – charity)

Temporary Housing Situation *

Transitional Housing – for homeless
Residential halfway house – no homeless criteria
Hotel (self-pay or friend)
Host home (no crisis)
Staying in a friend’s room, apartment or house
Staying in a family members room, apartment or house

Institutional *

Foster care or group home
Hospital or medical facility
Jail, prison or juvenile detention facility
Nursing home/long term care facility
Psychiatric hospital or facility
Substance treatment facility or detox center

Permanent Housing Situation *

Rental unit (no financial subsidy)
Rental unit (with financial subsidy)
Own home (no financial subsidy)
Own home (with financial subsidy)

Do you have a safe place to sleep tonight? *

Yes
No

Are you responsible for children or others who rely on you? *

Yes
No

If yes, do they currently stay with you? *

Yes
No

Do you have any urgent medical needs right now? *

Yes
No

Do you need medication that you don’t currently have access to? *

Yes
No

Do you have your ID or other important documentation? *

Yes
No

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