SHORT INTAKE FORM
UNIFORM REPORTING SYSTEM Page 1 of 3
Form date Sep 05
* NAME ~ PLEASE PRINT
* IDENTIFIERS
* CLIENT ID: * LAST NAME:
* FIRST NAME:
* INTAKE DATE:
/ /
* DATE OF BIRTH:
/ /
* GENDER:
Middle Name:
MONTH
MONTH
YEAR
DAY
YEAR
11 Male
ADDRESS
LIVING SITUATION * HOUSING:
Street:
City:
DAY
* STATE:
* ZIP CODE:
01 Homeless On Street 02 Homeless In Shelter
07 Skilled Nursing Facility Or Hospice
03 Transitional Housing
08 Hospital
04 Residential Psychiatric Facility
09 Correctional Facility (Jail / Prison)
05 Residential - Group Home 05 Residential-Drug Treatment
10 Permanent Housing Rental 11 Permanent Housing Owns Home 12 With Relations / Friends 13 Domestic Violence Situations
Chronic Homelessness (as defined by HUD)
* COUNTY: Select
One * PRIMARY LANGUAGE SPOKEN: Telephone:
( ) - ( ) - Day
Evening
Can Client Be Contacted?
✘ Discretion
Home Visit
(Please Check All That Apply)
By Mail
✘ Phone
Language Selection Language Selection
Language Selection
Language Selection