Initial Intake
Please fill out completely and to the best of your knowledge. Completing this form DOES NOT guarantee program placement.  
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Email *
Today's Date *
First Name *
Last Name *
Date of birth  *
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Phone Number
Marital Status *
Spouse/Partner name (first, middle, last)
Spouse/Partner Date of Birth
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DD
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YYYY
What brought you to your current situation?  *
Please give a brief explanation of what caused your current situation and any other important information.  *
When did this period of Homelessness begin? 
Have you applied at Benjamin's House in the past? *
Have you been a resident at Benjamin's House before? *
If yes, when? 
Please list First Name and Age of any children joining you. 
County of residence
Current Location (City) 
Other states of residence in the last 3 years
Do you have transportation? *
Are you employed?  *
Where did you sleep last night?
Do you have any history of drug or alcohol use?  *
We are required to run a background check. Is there anything we should expect to find?
 Probation or Parole? *
Probation/Parole officer name and county
Any involvement with Social Services? (Working with a Case Manager) *
Name and County of Social Worker
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