Homeless Outreach Rehabilitation Assessment Form
Use this form to assess housing situation, rehabilitation support needs, readiness to engage, and preferred follow-up details for outreach services.
Participant Information
Participant Full Name
*
First Name
Middle Name
Last Name
Preferred Contact Method
*
Phone
Text
Email
No Preference
Best Contact Details
Age Range
*
Please Select
Under 18
18–24
25–34
35–44
45–54
55–64
65+
Assessment and Support Needs
Current housing situation
*
Unsheltered
Emergency shelter
Transitional housing
Temporary stay with friends or family
Supportive housing
Other
Primary rehabilitation support needs
*
Case management
Housing assistance
Mental health support
Substance use support
Medical care
Employment support
Benefits assistance
Peer support
Life skills training
Other
Readiness to engage with services
*
Not ready
1
2
3
4
5
6
7
8
9
Fully ready
10
1 is Not ready, 10 is Fully ready
Immediate barriers to participation
Transportation
Schedule
Documentation
Safety concerns
Communication needs
Other
Follow-up Details
Preferred Follow-up Date and Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Preferred Outreach Location or Meeting Setting
Please Select
Shelter
Community Center
Phone Call
Video Call
Outreach Site
Other
Additional Notes or Concerns
Submit
Should be Empty: