This nonprofit template includes 7 fields. Screen and intake individuals and families seeking emergency shelter services at your nonprofit facility. Free to customize and use on ZenBuild.
Full Name (text, required)
Date of Birth (text, required)
Are you seeking shelter for yourself alone or with others? (multiple choice, required) — options: Myself only, Myself and children, Myself and partner/spouse, Family (two adults + children)
Number of people in your group (including yourself) (number, required)
Which services do you need? (Select all that apply) (checkboxes, optional) — options: Emergency Shelter, Meals / Food, Medical Referral, Case Management, Mental Health Support, Job Placement Assistance
Do you have any medical conditions or special needs we should be aware of? (multiple choice, required) — options: Yes — I will discuss with staff, No
