All Applicants Must Sign Below By signing below I attest that the information I have provided for eligibility and intake is a true and accurate account of the current situation, income and household. Client signature: _______________________________________________________ Date: ___________________ Agency Representative Name (print): ______________________________________ Agency Representative Signature: _________________________________________ Date: ___________________ (This Page Left Blank On Purpose) Universal Intake HH Member Supplemental Head of Household Name: HMIS ID# Fill-in after ServicePoint Entry Intake/Entry Date Month / Day / Year Client does not Client Name of Head of Household (first, middle, last name, suffix (e.g., Jr, Sr, III)) know refused First Name Middle Name   Last Name Alias/Suffix   Approx. or Partial SSN    SSN Reported Veteran Status is on the Client Profile Tab and may need to be updated Yes No   Veteran Status if the client is already in ServicePoint. Relationship HoH’s Child HoH’s Other Relation NA NA (to HoH) HoH’s Spouse/Partner Other: Non-Relation Approx. or Partial Date of Birth    DOB Reported
All Applicants Must Sign Below By signing below I attest that the information I have provided for eligibility and intake is a true and accurate account of the current situation, income and household. Client signature: _______________________________________________________ Date: ___________________ Agency Representative Name (print): ______________________________________ Agency Representative Signature: _________________________________________ Date: ___________________ (This Page Left Blank On Purpose) Head of Household Name: Universal Intake HH Member Supplemental HMIS ID# Fill-in after ServicePoint Entry Intake/Entry Date Month / Day / Year Name of Head of Household (first, middle, last name, suffix (e.g., Jr, Sr, III)) Client does not know Client refused First Name Middle Name   Last Name Alias/Suffix   SSN Approx. or Partial SSN Reported    Veteran Status Yes No Veteran Status is on the Client Profile Tab and may need to be updated if the client is already in ServicePoint.   Relationship (to HoH) HoH’s Child HoH’s Spouse/Partner HoH’s Other Relation Other: Non-Relation NA NA Date of Birth Approx. or Partial DOB Reported   
Universal_Intake_Form_20170622.docx