Intake Form
Serving the greater OKC and surrounding areas
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of birth
-
Month
-
Day
Year
Date
Desired move-in date
*
-
Month
-
Day
Year
Date
Do you smoke, vape or Chew tobacco ?
*
Yes
No
Gender
*
Male
Female
Other
Funding source
*
SSI
SSID
Housing Voucher
Private pay/ Self pay
Other
Organization funds
What type of assistance would you receive?
How did you hear about us?
*
Facebook
Craigslist
Family/Friends
Social worker/Case worker
Employment status
*
Full time
Part time
Self-employed
Unemployed
How long will you be with us?
*
Month to month
3 months
6 months
12 months
We have 2 beds to a room. Are you ok with shared living space?
*
Yes
No
Please give a brief description of your current situation.
*
Are you filling this Application out on behalf of someone else? If so please specify your role and contact information.
*
Yes
No
Relations to applicant
Title and Contact info
Date
*
-
Month
-
Day
Year
Date
Emergency contact number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship status
*
Married
Divorced
Widowed
Separated
Single
Emergency contact
*
First Name
Last Name
Upload a valid ID
Browse Files
Drag and drop files here
Choose a file
Driver’s License, State ID, Passport
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of
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