Multiple Individual Intake Form

Name of Head of Household: *

First Name

Last Name

Phone *

(###)

###

####

Is there anyone under the age of 18 in your household? *

Yes

No

Today's Date *

MM

DD

YYYY

Which best describes your race/ethnicity? Please check all that apply. *

American Indian or Alaska Native

Asian

Black or African-American

Hispanic or Latin

Native Hawaiian or Pacific Islander

Middle Eastern or North African

White

Prefer not to say

What is your gender identity? *

Male

Female

Transgender

Other

Prefer not to say

Did a social worker or support person refer you to PAVE? *

Yes

No

By what date do you need housing? *

MM

DD

YYYY

Do you or anyone in your household have pets? *

Yes

No

Are you open to co-living? (This means your having your own room and sharing common areas like bathrooms and kitchen) *

Yes

No

Do you or anyone in your household require any reasonable accommodations? *

Yes

No