AMGHS Client Intake Form

A Meaningful Goal Housing Shelter program participants receive specialized support designed to help them secure and maintain permanent housing. Please complete and submit the required information below as recommended by AMGHS staff.^** AMGHS supports individuals in South Los Angeles County, CA.

^**If you have not yet spoken with AMGHS regarding receiving our services, please first complete the introductory Request Services Form, and one of our helpful staff members will reach out to you as soon as possible.

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Your Name *

First

Middle

Last

Your Date of Birth *

Please use the following format: MM/DD/YYYY

Sex Assigned at Birth *

• Female
• Male

Current Gender Identity (select all that apply) *

• Woman
• Man
• Non-binary
• Agender
• Genderfluid
• Genderqueer
• Transgender
• Prefer not to say

Phone Number *

Phone Type

• Cell / Mobile
• Work
• Other

Email Address *

Home Address Line 1 *

Home Address Line 2

City *

State *

Zip Code *

Emergency Contact: Name *

Emergency Contact: Phone Number *

Is this a mobile phone number?

• Yes
• No

Emergency Contact: Relationship to You *

• Spouse/Partner
• Parent/Guardian
• Sibling
• Child
• Friend
• Relative
• Neighbor
• Co-worker
• Other

Demographics: Race/Ethnicity (select all that apply)

• American Indian or Alaska Native
• Asian
• Black or African American
• Hispanic or Latino
• Middle Eastern or North African
• Native Hawaiian or Pacific Islander
• White

Demographics: Veteran Status

• I am a protected veteran
• I am NOT a protected veteran

Demographics: Justice-Involved

• Yes
• No

Health: Do you have a disability? *

• Yes
• No

If yes, please specify:

Health: Are you currently receiving any mental health services? *

• Yes
• No

Health: Do you have health insurance? *

• Yes
• No

Housing Status: Which best describes your current situation? *

• Stable Housing
• Temporary Housing
• Homeless
• At Risk of Homelessness

Current Employment Status: *

• Employed
• Unemployed

Are you interested in learning about employment support resources?

• Yes
• No

Highest Level of Education Completed: *

• No schooling completed
• Nursery school to 8th grade
• Some high school, no diploma
• High school graduate (or equivalent, e.g. GED)
• Some college credit, no degree
• Trade/technical/vocational training
• Associate degree
• Bachelor’s degree
• Master’s degree
• Professional degree
• Doctorate degree

Are you interested in learning about training or education resources?

• Yes
• No

Current Source of Income (select all that apply)

• Salary/Wages from Employment
• Self-Employment
• Government Assistance
• Other Source
• None

AMGHS Services Requested: How can we help? (select all that apply) *

• Housing Assistance
• Employment Support
• Education/Training
• Mental Health Services
• Case Management
• Other

If Other, please specify:

Current Situation: What challenges or barriers are you facing today? *

of signature: Demographics:

Goals: What are your short-term goals? *

Goals: What are your long-term goals? *

Do you consent to participate in AMGHS services? *

• YES
• NO

By checking “YES” above, you agree to participate in AMGHS’s voluntary program and receive AMGHS services. You also agree to abide by all health and safety rules and regulations, to cooperate with AMGHS and its third-party partner agencies in the process of rendering services requested, and to make a full-faith effort to reach agreed-upon goals discussed between you and your primary point of contact at AMGHS. Failure to comply will result in discharge from the AMGHS program.

Do you grant permission for AMGHS to share necessary information with partner agencies? *

• YES
• NO

By checking “YES” above, you grant permission for AMGHS to share any necessary information with third-party partner agencies. Information will be shared only for the explicit purposes of seeking required referrals and related supportive services as part of the regular process of receiving AMGHS services.

Your signature: *

By typing your full legal name above, you understand and agree that this form of electronic signature has the same legal force and effect as a manual signature. Your signature means that all information provided in this form is truthful and accurate to the best of your knowledge. Your signature is required to process this request.

Today's date: *

Please use the following format: MM/DD/YYYY

Submit