Housing Intake Questionnaire

HOUSING INTAKE QUESTIONNAIRE

RECITALS

Provider Name:

Client Name:

WHEREAS, Provider administers housing placement, case management, and related supportive services and maintains procedures to evaluate client housing needs and eligibility; and

WHEREAS, Client seeks assessment and assistance in obtaining and maintaining safe and stable housing and agrees to provide accurate information to enable Provider to make informed determinations regarding services; and

NOW, THEREFORE, the parties record the client intake information and the terms under which Provider will evaluate and, where applicable, provide housing-related services as further set forth below.

APPLICANT INFORMATION

Length of time at current address:

HOUSEHOLD AND DEMOGRAPHICS

Yes No

HOUSING HISTORY

Eviction history within last 7 years: Yes No

INCOME AND BENEFITS

Public benefits received (check all that apply):
SSI SSDI SNAP TANF None

NEEDS, BARRIERS, AND ACCOMMODATIONS

EMERGENCY CONTACT

CONSENT, AUTHORIZATIONS AND CERTIFICATIONS

By signing below, Client certifies that all information provided on this Intake Questionnaire is true, complete and accurate to the best of Client's knowledge. Client authorizes Provider to verify information, including housing, income, employment and rental history, and to obtain consumer reports as necessary to determine eligibility for housing services. Client understands false statements may constitute grounds for denial of services.

Client consents to verification and background checks as described above.

SCOPE OF WORK

The parties agree that Provider will undertake assessment, referral, placement assistance, and limited case management to secure housing for Client. Specific tasks may include eligibility review, landlord negotiation, subsidy application assistance, and referrals to supportive services. Provider does not guarantee placement and will act consistent with applicable policies, capacity, and available resources.

PAYMENT TERMS

If service fees apply, Client agrees to pay Provider in accordance with the terms below. Fees assessed will be limited to those expressly disclosed in writing and in compliance with program rules.

TERM AND TERMINATION

This Agreement and any services described herein commence on the Start Date and continue until the End Date, unless earlier terminated as provided below. Provider or Client may terminate services for material breach, fraud, or failure to cooperate. Client must provide written notice to terminate; Provider will provide written notice of termination and, where appropriate, a remedy period.

CONFIDENTIALITY

All non-public information provided by Client to Provider in connection with intake and delivery of services shall be treated as confidential and used solely for purposes of evaluation, placement, and service delivery, except as necessary to comply with legal obligations, to protect health and safety, or when Client provides express written consent. Provider will maintain reasonable safeguards to protect client records and information.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state of the Provider's principal place of business, without regard to conflict-of-law principles. Any dispute arising under this Agreement shall be resolved in the courts of that jurisdiction, subject to applicable mandatory procedures for administrative review where required.

ENTIRE AGREEMENT

This Intake Questionnaire together with any attached service schedule or fee disclosure constitutes the entire agreement between Provider and Client relating to the intake assessment and any short-term housing assistance described herein and supersedes all prior statements, communications, or understandings, whether oral or written. Any amendments must be in writing and signed by both parties.

ADDITIONAL INFORMATION

Sign Now