NEW APPLICANT INTAKE FORM

NEW APPLICANT INTAKE FORM
ALL SECTION'S OF THIS FORM MUST BE COMPLETED AND MUST BE TRUE AND ACCURATE TO THE APPLICANT'S KNOWLEDGE.
FIRST NAME*
MIDDLE NAME
LAST NAME*
SS#*
Social Security
EMAIL*
example@example.com
PHONE #*
HEIGHT*
DOB*
WEIGHT*
DL# or ID#*
Driver License or Identification
EYE COLOR*
EMERGENCY CONTACT
FIRST NAME*
LAST NAME*
EMAIL *
example@example.com
PHONE #*
CASEWORKER INFORMATION
FIRST NAME*
LAST NAME*
EMAIL*
example@example.com
PHONE #*
ORGANIZATION*
PHONE #
Organization phone #
HOW LONG HAS THE CLIENT AND CASE MANAGER BEEN WORKING TOGETHER?*
APPLICANT QUESTIONNAIRE
Please make sure the applicant has all of the following (check all that apply):*

Valid State or Government issued identification cardCurrent SSI/SSDI Award LetterMove in Funds: 1st month’s rent + depositClean background check
Has the applicant ever been convicted of a felony or misdemeanor?*

YesNo
Applicant and Caseworker understand and agree that living quarters include a shared room with 2 beds.*

YesNo, I need a private room
Has the applicant lived in a Shared / Co-living environment before?*

YesNo, this is first time in a shared living environment
Tell us a little about the applicant (please adhere to HIPAA)*
We can provide the environment to be successful. Is there anything else you can tell us that would assist us in helping the applicant reach their goals?*
We want to provide an environment for our residents to stay successful. Caseworkers provide the discharge plan and we provide the environment. Is your client ok with a no alcohol, no drugs, no overnight guests policy?*

YesNo
Is the applicant Ambulatory? Some properties have stairs or a step up/down entering the property that the applicant will have to navigate.*

YesNo
Is the applicant able to cook, clean, and perform daily chores including light housekeeping of their bedroom and common areas, and their bathroom?*

YesNo
Can the applicant take any medication (if needed) and schedule their Doctor appointments unassisted?*

YesNo
Income – is the applicant on SSI/SSDI/Voucher or have another source of income?*

SSISSDIVoucherOther, please describe____________________________________________
Does the applicant have a 3rd party representative payee?*

YesNo
Hygiene – Can the applicant bathe and maintain hygiene unassisted?*

YesNo
We do not provide any services (food, transportation). Does the applicant have access to these services?*

YesNo
When is the applicant available for an interview and tour?*
Example: September 15, 2024 12:30 PM
When would the applicant available like to move in?*
Example: September 15, 2024 12:30 PM
How did you hear about us?*

Search engine (Google, Yahoo, etc)Recommended by case manager or social workerSocial MediaRecommended by family or friendOther
Applicant authorizes Piercing Instincts to contact themselves, their program, their case worker and any other sources deemed necessary to verify applicant information provided. Applicants is aware and in agreement that we will run a full background check on every application. All information is true, accurate, and complete to the best of the applicant's knowledge. We have authorization to release information about the undersigned upon presentation of this form or a photocopy of this form at any time. Applicant agrees to the terms of this form as stated above.
Print Name*
Date*

MonthDayYear
Date
Signature*

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Should be Empty:

NEW APPLICANT INTAKE FORM

EMERGENCY CONTACT

CASEWORKER INFORMATION

APPLICANT QUESTIONNAIRE