CAC/IT99867

EIN 99-2852373

Restoration For The Future Foundation

Brief Beneficiary Intake & Needs Assessment

Staff-assisted confidential service-navigation intake.

1

Basic Information

Age
Children with you?
2

Current Housing Situation

Where are you staying now?
Without stable housing
First time homeless?
Case manager now?
3

Housing Assistance

Would you like help finding housing or shelter?
Applied before?
If yes, what happened?
4

Documents

Do you currently have:
5

Income & Benefits

Any current income?
Benefits received
6

Services You Would Like Help With

Check all that apply
7

What Is Stopping You From Getting Housing?

Check all that apply
8

Knowledge / Past Help

Do you know what housing or assistance programs are available?
Have you tried getting help before?
9

Your First Priority

10

Permission to Follow Up

May RFF contact the participant about the help requested?
May RFF connect the participant with appropriate partner organizations?
Preferred contact method
Staff

Staff Use

Immediate follow-up needed?
PIN

Submission Authorization

Confidentiality reminder

Collect only information needed for service navigation. Handle personal information confidentially and according to RFF policies and applicable requirements.