Housing Related Services & Supports (HRSS) Intake Form
This form helps us determine your eligibility for Utah’s Housing Related Services and Supports (HRSS) program. The HRSS program provides housing-related help to Medicaid members who are experiencing homelessness, housing insecurity, or other serious challenges. Please complete all questions as accurately as possible. A team member will contact you to review your information.
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Full Name
Date of Birth
MM
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DD
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Phone Number
Email Address
Current Address or Location
Preferred Method of Contact
Clear selection
Are you currently enrolled in Utah Medicaid?
Clear selection
Are you part of the Targeted Adult Medicaid (TAM) program?
Clear selection
Medicaid ID Number (if known)
Where are you currently staying?
Clear selection
How long have you been in your current situation?
Have you been homeless for 12+ months total or 4+ separate times in the last 3 years?
Clear selection
Have you ever been involved in any of the following?
Do you need help with any of the following?
Do you currently receive services from a case manager, therapist, or social worker?
Clear selection
If yes: Please provide their name and organization.
Which HRSS services are you interested in?
What are your most urgent housing needs?
Do you have any pets that would move with you?
Clear selection
Do you have accessibility needs (e.g., wheelchair ramp, ground-floor unit)?
Anything else you’d like us to know?
Consent Agreement
Digital Signature (Type your full name)
Date
MM
/
DD
/
YYYY
Submit
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