Emergency Housing Intake Checklist Form
Complete this checklist to assess emergency housing needs and placement readiness.
Applicant Full Name
*
First Name
Last Name
Contact Information (Phone and/or Email)
*
Household Size
*
Immediate Housing Need
*
Displacement (eviction, disaster, etc.)
Unsafe situation
Loss of previous housing
Other
Emergency Contact Name and Phone
*
Required Accommodations
Wheelchair accessible
Family/children space
Pet-friendly
Quiet space
Other
Current Shelter Status
*
Unsheltered (outside, vehicle, etc.)
Temporarily staying with friends/family
Currently in shelter
Other
Check-In Readiness
*
Ready to check in today
Ready to check in within 48 hours
Needs more time
Documents Available
Photo ID
Proof of residence
Birth certificate(s)
None
Other
Staff Notes (for internal use only)
Submit Checklist
Should be Empty: