WESTBROOK’S SOLUTIONS Client Screening Form Date Personal Information Full Name *Date of Birth *Phone Number *Email Address *Current Address * Emergency Contact Name *Relationship *Phone * Housing History Current Living Situation *How long at current residence *Reason for leaving current housing * Employment & Income EmployedUnemployedRetiredOtherEmployer/Source of Income *Monthly Income * Health & Support Section Do you have any medical conditions we should be aware of? *YesNoIf yes, please explainAre you currently on medication? *YesNoIf yes, please list Behavior & Lifestyle Have you ever been involved with probation, parole, or reentry programs? *YesNoOther (please specify)Are you able to live independently with a structured environment? *YesNoOther (please specify)Do you have any special needs or accommodations? *YesNoOther (please specify) Agreement I certify that the information provided above is accurate to the best of my knowledge. I understand that providing false information may affect my eligibility for housing.Signature *Your browser does not support e-Signature field.Date *Submit
