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)