This document is an intake assessment for housing and community support services that collects information about an individual's basic demographic details, current housing situation, health, income, benefits, and potential barriers to obtaining housing. It asks questions about topics like homelessness history, housing needs, mental health, substance use, domestic violence, family situation, employment, income sources, spending on housing, rental history, credit, and criminal background. The assessment is meant to help staff understand an individual's full circumstances and needs to determine what assistance may be required for housing stability.

1. New Horizons Behavioral Health Community Support Services
Barriers to Housing Stability and Intake Assessment
Please complete the entire form and return to the staff member at the front desk.
BASIC INFORMATION
Name: ________________________________________________________________________
Date of Birth: _______________________ Today’s Date: ________________________
Phone Number: ______________________ Are you a veteran? YES NO
Age: _______________ Gender: ________________ Race:__________________
CURRENT HOUSING ASSESSMENT
Are you currently homeless (living on the street, in a shelter, in a hotel, or in a place not meant
for habitation)?
□ Yes □ No
How many times have you been homeless in the past 12 months? _________________________
How many times have you been homeless in the past 3 years? ____________________________
Have you received an eviction notice or are in the process of being evicted?
□ Yes □ No □ Unknown
Where did you sleep last night? ____________________________________________________
Do you need temporary or permanent assistance to get or keep housing?
□ Yes, temporary assistance □ Yes, permanent assistance □ No □ Unknown
Please give a description of your current housing situation and needs:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. HEALTH AND PERSONAL ASSESSMENT
Mental Health
Do you have a diagnosis of a mental illness or been told that you do?
□ Yes □ No □ Unknown
If yes, please list your diagnosis: _____________________________________________
Do you have mental health issues that have caused you to lose your housing in the past?
□ Yes □ No □ Unknown
Do you have mental health issues that currently affect your ability to get housing?
□ Yes □ No □ Unknown
Are you currently in treatment for mental health (counseling, therapy, medication management)?
□ Yes □ No □ Unknown
Substance Use
Has substance use (drugs and/or alcohol) caused you to lose your housing in the past?
□ Yes □ No □ Unknown
Does current substance use affect your ability to get housing?
□ Yes □ No □ Unknown
Are you currently in treatment for substance use?
□ Yes □ No □ Unknown
Physical Health
Have your physical abilities or physical health ever caused you to lose your housing?
□ Yes □ No □ Unknown
Does your physical health or abilities currently affect your ability to get housing?
□ Yes □ No □ Unknown
Domestic Violence/Abuse
Has domestic violence or abuse ever caused you to lose your housing in the past?
□ Yes □ No □ Unknown
Does domestic violence or abuse currently affect your ability to get housing?
□ Yes □ No □ Unknown
Family Composition
Do you currently have any children under age 18 in your household?
□ Yes □ No □ Unknown
Do you have any children under age 18 that you expect will live with you when you obtain
housing?
□ Yes □ No □ Unknown

3. INCOME AND BENEFITS ASSESSMENT
Do you have a job or receive wages for work?
□ Yes □ No □ Unknown
If yes, please list the amount you earn per month: _______________________________
Do you need assistance with finding new or additional employment?
□ Yes □ No □ Unknown
If yes, what type of employment are you looking for? ____________________________
Are you currently receiving Supplemental Security (SSI) or Disability (SSDI) income?
□ Yes □ No □ Ineligible □ Unknown
If yes, please list the amount you receive per month: _____________________________
Are you currently receiving TANF?
□ Yes □ No □ Ineligible □ Unknown
If yes, please list the amount you receive per month: _____________________________
Are you currently receiving child support?
□ Yes □ No □ Ineligible □ Unknown
If yes, please list the amount you receive per month: _____________________________
Are you currently receiving assistance from the public housing authority?
□ Yes □ No □ Ineligible □ Unknown
If yes, please list the amount you receive per month: _____________________________
Are you currently receiving food stamps?
□ Yes □ No □ Ineligible □ Unknown
If yes, please list the amount you receive per month: _____________________________
Are you currently receiving health insurance?
□ Yes □ No □ Ineligible □ Unknown
If yes, please list the amount you receive per month: _____________________________
Do you need assistance applying for any of the benefits listed above?
□ Yes □ No □ Unknown
If yes, please list the benefits you need assistance with: ___________________________
If you are living in a house or apartment, what percent of income do you spend on housing
(rent/mortgage AND utilities)?
□ 35% or less □ 36-50% □ 51-65% □ 66-80% □ 80% or more □ Unknown
If you are not living in your own house or apartment, how much money can you spend on
housing (rent/mortgage AND utilities) each month?
□ $0 □ $1-100 □ $101-200 □ $201-300 □ $301-400 □ $401-500
□ $501-600 □ $601-700 □ $701-800 □ more than $801 □ Unknown

4. HOUSING BARRIERS ASSESSMENT
Rental History
Have you ever had a lease for an apartment/home or utilities in your name? Check all that apply.
□ Yes, a lease □ Yes, utilities □ No □ Unknown
How many times have you been evicted from housing?
□ 0 □ 1 □ 2-3 □ 4-9 □ 10 or more
Would a prior landlord(s) give you a bad reference?
□ Yes □ No □ Unknown
Credit History
Do you have unpaid rent or utility bills in your name?
□ Yes □ No □ Unknown
If yes, please list the unpaid amount(s) here: ____________________________________
Do you have a credit history?
□ Yes □ No □ Unknown
Do you have poor credit?
□ Yes □ No □ Unknown
Criminal History
Have you ever been convicted of one or more misdemeanors?
□ Yes □ No □ Unknown
Have you ever been convicted of a felony?
□ Yes □ No □ Unknown
If yes, did the felony involve drugs, weapons, or a sex crime?
□ Yes □ No □ Unknown
Are you currently on probation?
□ Yes □ No
If yes, what is the date your probation expires? __________________________________
Is there anything not mentioned in this assessment that you need assistance with?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Thank you for completing this intake assessment. Please give this form to the staff member
at the front desk. One of our intake staff will speak with you shortly.