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INTAKE
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*
" indicates required fields
Client Name
*
Date:
MM slash DD slash YYYY
Telephone - Home:
*
Second phone number:
Email address:
*
Client address:
*
County
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
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Barbados
Belarus
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Bhutan
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Cameroon
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China
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Colombia
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Congo, Democratic Republic of the
Cook Islands
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Disasters Affected
*
2015 Floods
2016 Floods
Hurricane Harvey
Did you relocate after the storm?
Yes
No
Total number of people in household:
1
2
3
4
5
6
7
8
9
10
10 or more
Other
Untitled
Household demographics
Senior
Children under 10
Disabled
Veteran
Other
Untitled
Other assistance received:
FEMA
Insurance
Financial Assistance
Base Needs
Case management from other agency
Other
Untitled
Are you currently working with another agency who is providing case management?
*
Yes
No
Provide the name of the agency who is providing you with case management:
*
Describe the nature of assistance client is seeking:
*
Financial Assistance
Housing
Transportation
Mental Health
Repair/Rebuild
Food/Basic Needs
Other
Untitled
Briefly describe your current disaster situation:
*
Describe how a three-month stay in an apartment will aide you in your Hurricane Harvey disaster recovery:
*
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