______________ Middle ______ *Last Name* _____________________ *Suffix _____ (Jr/Sr.) *Social Security No. ____________________________________________ Intake Date _______________________ Intake Counselor _____________________________________________ Agency /Program_________________________________________ Services Requested at Intake (check all that apply): Housing o o o o o Services/Other Emergency shelter Rental assistance Housing Section 8 Security deposit o o o o o o Health Basic n.
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How to fill out the CA Standardized HMIS Intake Form online
Filling out the CA Standardized HMIS Intake Form online is an important step in seeking assistance and services related to homelessness. This guide provides clear, step-by-step instructions to help users navigate the form efficiently and accurately.
Follow the steps to complete the form online with ease.
- Click ‘Get Form’ button to obtain the form and open it in your online editor.
- Begin by filling in the personal details at the top of the form. Input your first name, middle name (if applicable), last name, and suffix if you have one. Next, enter your social security number and the intake date.
- Identify the intake counselor by entering their name in the designated field.
- Specify the agency or program you are applying for by writing its name in the appropriate box.
- In the 'Services Requested at Intake' section, check all the services that apply to your needs, such as housing assistance, health services, or employment training.
- Provide details about your language proficiency by responding to whether you speak and understand English. If not, specify your preferred language.
- Indicate who referred you to this program by selecting from the options provided or entering a response in the 'Other' section.
- Fill in your nickname, maiden name, birth date, and gender, selecting from the options provided for gender.
- If applicable, list any other adults who are applying for services with you, their relationship to you, and check the appropriate boxes related to their information.
- Respond to questions about your household, including whether you are the head of household and the total number of adults and children in your household.
- Continue filling out the sections regarding your contact information, last permanent residence, current mailing address, and living situation prior to entering the program.
- Complete the series of questions regarding your past living situation, including the length of time at your last residence and your housing status at program entry.
- Answer questions regarding military service, ethnic background, and potential disabilities.
- For dependent children under 18, please enter their information, including their name, birth date, gender, and relationship to you.
- Conclude by providing information regarding employment status and income details, including any financial resources received in the past 30 days.
- Finally, review all entries for accuracy. You will have options to save changes, download, print, or share the completed form as you see fit.
Complete your CA Standardized HMIS Intake Form online today!
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