R3 Intake Form — Personal Profile / Service Plan

This intake form gathers the information R3 case managers use to build a Personal Profile and Service Plan. Fill it out together with a participant, or have a participant complete it themselves — everything saves automatically as you go.

01 — Personal Profile

Who we're meeting

R3 Site Location *

Kapolei Library Paradise Chapel of the Assemblies of God

Name *

Date of Birth *

SSN

Contact # *

Are you living alone or with others?

Alone With Others

Household members

Where is your set up? / Where did you sleep last night?

What was your sex assigned at birth? *

Male Female

Have you ever served in the U.S. Armed Forces? *

Yes No

Do you have any pets? *

Yes No

Is it an emotional support or service animal?

Yes No Unknown

Has owning a pet prevented you from entering a shelter and/or permanent housing?

Yes No Unknown

03 — Homeless Verification

Documentation on file

Added to HMIS system

Who we're meeting

Health & safety

Documentation on file

In their own words

Next steps

Sign off