The purpose of this form is to determine your specific needs. Some examples of needs are: help with re-entry into your local community, and other services and benefits that may be applicable to you. We will review all of the information that you provide us with. A plan and one-on-one interview with you to process your requests will be conducted. Listed below is a list of services that may apply to you. We will do our best to assist you.

Please check the box(es) that apply to you and answer the applicable questions:

Name: __________________________________________________ Date: ______________________

Gender:   Male ☐     Female ☐     Age: ___________   Veteran ☐

Married ☐     Single ☐     Separated ☐     Divorced ☐     Number of Children: ______________

Other Family Members that are with you and ages: _____________________________________________________________________________________

Contact Information: Cell Phone:____________________________    email:__________________________________

Finances – Monthly Basis

Employment Income                          $ ________________________________

VA Compensation ( %) ________        $ ________________________________

Social Security/Welfare                      $ ________________________________

Other                                                $ ________________________________

Expenses – Monthly Basis

Home Mortgage or Apartment Rent $ ________________________________

Utilities $ ________________________________

Food $ ________________________________

Loan(s) $ ________________________________

Other (Car Insurance, etc…) $ ________________________________

Are you interested in assistance in any of the following:

☐ Employment     ☐ Housing     ☐ Food     ☐ Transportation

Transition Plan

Do you know how a plan can help you begin your transition back into the community?

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Can you name two places where you can find resources that will aid you in completion of your transition back into the community? ______________________________________________________________________________________ ______________________________________________________________________________________

Where will you continue to locate resources in the community? ______________________________________________________________________________________

How will you contact agencies in the community to receive the most assistance? ______________________________________________________________________________________

Employment

Housing

Do you know where do you plan to live?

If you need to go to a shelter, do you know where they are located and how do you contact them?

Do you have a picture ID to enter the shelter? If not, how can you obtain one?

Do you have the addresses, telephone numbers and admission requirements of the shelters?

Do you know what agencies might help you with rental assistance to obtain a room or apartment?

Food

Do you know where might you apply for food stamps?

Do you know where the local Social Services office is located?

Do you know the names and addresses of food pantries/closets in the area?

Do you know what other options you have for obtaining food?

Transportation

Do you know how will you get around?

Do you have access to a car or truck?   If not, how will you travel?

Do you know the agencies in your community that can assist you with transportation issues?

Are you familiar with the public transportation in your community? If not, where can you learn about it?

Do you have other transportation issues, i.e. suspended licenses, fines, etc.?   If so, what do you plan to do about these issues?

Use the space below to provide specifics on what benefits and services you desire that were not addressed above. ______________________________________________________________________________________

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Insightful Solutions Consultant’s Comments:

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ISC Homeless Service Form 1 – Homeless Needs Assessment and Service Request  (v.1.0 - Jan 17)