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HomesUnited 2024 Requests form for Intake
HomesUnited will review each request thoroughly and try to respond within 48 hours with a confirmed placement decision. Please feel free to contact us directly if we have not responded in allotted designated time with a decision @ 954-981-9301.
* Indicates required question
Email
*
Record my email address with my response
Date of Housing Request
MM
/
DD
/
YYYY
Expected admission Date into HomesUnited
MM
/
DD
/
YYYY
Case Manager or Requestor
Your answer
Contact Phone Number
Your answer
Email of Requestor
Your answer
Client Full Name
First Name Last Name
Your answer
Phone Number of Client
Your answer
DOB of Client
MM
/
DD
/
YYYY
Gender Identity
Male
Female
Prefer not to say
Clear selection
Race
Black
White
Native American/Alaskan Native
Native Hawaiian
Asian
Multi Racial
Clear selection
Ethnicity
African American
Hispanic/Latino
Jamaican
Haitian
Clear selection
Client Next of Kin or Emergency Contact:
Name & Phone Number
Your answer
Social Security Number (SSN)
Your answer
Benefits Status
Active
Inactive
No Benefits
Clear selection
Current Benefits
Food Stamps (SNAP)
TANF
Medical Assistance
SSI
SSDI
Financial Assistance from Third Party
Is client receiving Food Stamps (SNAP)?
Yes
No
Had previously but need to reinstate
Clear selection
Amount of Benefits and Explanation (if no benefits/inactive)
Your answer
Insurance
Medicaid
Medicare
HMO
PPO
Other:
Insurance Company (if applicable)
ie. Cigna, Aetna, United Healthcare, Molina, Magellan, etc.
Your answer
Primary Diagnosis
Mental Health
Substance Use
Co-Occuring/Dual Diagnosis
Other:
Clear selection
What substance have you used/abused in the past?
Including current substance(s) of choice if in active addiction
Alcohol
Marijuana/THC
Cocaine
Methamphetamine/Uppers
Benzodiazepines/Xanax
Oxycodone
Opiates
Fentanyl
Flakka
None
Other:
Legal History:
How many years have you been in jail/prison/on probation?
0-1 year
1-5 years
5-10 years
10 or more years
Other:
Clear selection
Are you currently on probation or awaiting court date?
No
Yes
Other:
Clear selection
Court date and Assigned Judge (if applicable)
MM
/
DD
/
YYYY
Employment Status
Full time
Part time
Terminated/Unemployed
Student
Active Military
Veteran
Unpaid Family Worker
Homemaker (Must keep house for 1 or more others)
Disabled
Criminal Inmate
Leave of Absence
Retired
Not authorized to work
Clear selection
What is the date client first became homeless?
MM
/
DD
/
YYYY
What were circumstances leading up to homelessness?
Your answer
Number of times client has been homeless on the street/in a shelter in the past 3 years, including today:
0
1
2
3
4 or more
Clear selection
Mental Health Diagnosis (Diagnoses)
Your answer
Name and Address of Psychiatrist
Your answer
Medications (Psychiatric)
Your answer
Physical Medical History
Does client have any medical diagnoses or disabilities requiring additional medical services? ie. need for dialysis, ostomy bag, wheelchair, etc.
Your answer
Medications (Excluding psychiatric)
Your answer
Name and Address of Medical Doctor (PCP or Specialist):
Your answer
Client's Plan for Discharge/Graduation from HomesUnited:
Your answer
Terms
I agree to provide the above to HomesUnited for placement in housing.
I will not provide the information above to HomesUniited for placement in housing.
Clear selection
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