testt INTAKE ASSESSMENT Name: Email: Phone #: Date: Referral: Personal Information Age: Gender: MaleFemale If female, are you pregnant?: YesNo If yes, due date?: Veteran?: YesNo Disabled?: YesNo Marital Status: MarriedDivorcedSeparatedWidowedSingle Can you speak fluent English? YesNo Housing Information Previous/Current address: City: Zip Code: How long? If no previous address is applicable, what was your living situation immediately prior to this application : Residential care / Treatment Board and CareHospitalPrison/JailHomeless ShelterHomeless (i.e. street) Reason for leaving your previous/current housing: Legal Information/History Currently on probation? YesNo Parole? YesNo Parole/Probation Officer Contact Name: Phone #: () Pending Case(s): YesNo Court Dates: Income Information Source of Income: NonePublic AssistanceRetirementSocial Security/DisabilitySSIWelfareAlimony/Child SupportOther (specify) Employment Status Highest Level of Education: Do you own a car? yesNo Employed FTEmployed PTUnemployed (must be currently looking)Attending school/programNon-competitive/Volunteer workOther (specify): If employed, provide company name and phone number, your position, your manager, and your days & hours of work: Why are you looking to become a member of Trinity Living, Inc.? What goals would you like to achieve?
