Intake Assessment Form

Victory is OURZ Housing LLC

Applicant First Name *

Applicant Last Name *

Date of Assessment *

Phone Number *

Emergency Contact Name *

Emergency Contact Phone *

Current Living Situation *

With family

Homeless

Shelter

Transitional housing

Other

Able to manage daily routine? *

Yes

No

If no, please explain

Able to clean and maintain living space? *

Yes

No

Okay with shared living? *

Yes

No

Able to cook or prepare meals? *

Yes

No

Currently working/in school/in program? *

Yes (specify)

No

Looking for opportunities

If yes, please describe

Takes prescribed medications? *

Yes

No

Takes medications independently? *

Yes

No

Medical conditions? *

Yes

No

If yes, please describe:

Receiving mental health support? *

Yes

No

Alcohol use? *

Yes

No

Marijuana use? *

Yes

No

Other drugs use? *

Yes

No

Any Nicotine products *

Yes

No

Substance abuse description

Willing to live in drug/alcohol/smoke-free environment? *

Yes

No

Substance abuse treatment program? *

Yes

No

If yes, when and where?

Violent behavior or aggression history? *

Yes

No

If yes, please explain

Able to follow a curfew? Unless approved *

Yes

No

No visitors/overnight guests? *

Yes

No

Participate in chores? *

Yes

No

Attend meetings/check-ins? *

Yes

No

Open to staff feedback? *

Yes

No

Any pets? *

Yes

No

Motivation

Short-term goals

Long-term goals

Support needed

Current source of income *

Yes

No

Income source *

Employment

SSI/SSDI

Family

Assistance

Other

Monthly income *

Able to afford program fee? *

Yes

No

Unsure

Financial obligations *

Yes

No

If yes, please explain:

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