Kingsley Group Intake form

The Kingsley Group

Independent Living Housing Intake Form
Thank you for your interest in The Kingsley Group. While we are an independent housing program, availability is limited. At the time you apply, there may be a waiting period, as placements are handled on a first-come, first-served basis. We kindly ask for your patience during this process. If we are unable to place you within The Kingsley Group, we will assist you in connecting with another suitable program.
*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Client Social Security Number *
Gender*

MaleFemaleTrangenderN/A
Do you have a working phone and phone number?

Working phone/YesWorking phone/NoPhone number/YesPhone number/No
*
Please enter a valid phone number.Format: (000) 000-0000.

Currently have transportation.

FamilyPublic transientPersonal vehicleWill need assistance
Do you have health insurence*

YesNo
For individuals with active insurance, kindly list your insurance provider.
Please upload proof of insurance.*

Cancelof
Do you have a government or state ID?*

YesNo
Please upload a copy *

Cancelof

Emergency Contact Name

First NameLast Name
Emerency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Representative Name (case worker, social worker or program contact)

First NameLast Name
Representive's Phone Number (case worker , social worker or program contrat)
Please enter a valid phone number.Format: (000) 000-0000.
Representative's Email (case worker, social worker or program contact)
example@example.com
When does the client need to be place?*

MonthDayYear
Date

Have you been diagnosed with or experienced any mental health-realted challenges?*

YesNo
If yes, please list any mental health conditions you're currently managing. (Example: Depression, Anxiety, PTSD, Bipolar Disorder, etc.)*
Are currently taking any precribed medication for your mental helath conditions?*

YesNo
Do you have any physical health conditions or disabilities we should be aware of?*
Do you have any history of substance abuse?*

YesNo
If yes, how long have you been sober and are you current in a program?*
Do you us any tobacco products?*

YesNo

Have you ever been convicted of a crime? Please note, answering yes does not automatically disqualify you.*

YesNo
City and state of conviction:*
If you answered yes to the above question, please explain:*
Are you currently on Probation or Parole?*

YesNo
Are you a registered sex offfender?*

YesNo

What type of room do you prefer?*

Private Rooms/starting at $700Shared Rooms/starting at $600
Do You Need Assistant with Any of the Following? (This helps us understand how to best support your transition and connect you with helpful resources)

Applying for SNAP (Food Stamp) BenefitsApplying for SSI/SSDIApplying for VA BenefitsMedication Pick-Up or Reminders (Note: We do not administer medications)Obtaining a State ID or Birth CertificateSetting Up a bank AccountJob Search or Resume Help for better Job

Pets are not permitted; only documented service animals are allowed. Do you have any pets?

YesNo
If you possess valid documentation for your service pet, please upload it here

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Room Sharing for Parents

At The Kingsley Group, we believe families thrive best when they’re together. Mothers and fathers in our program will share a room with their child or children to create a safe, comfortable, and supportive family environment. This setup helps parents stay connected with their kids while building stability and independence.
Section: For Mothers/Dads with a Child(ren): Please list the names and ages of your child(ren): *
Do your child(ren) have any special needs, medical conditions, or support requirements?

I certify that the information provided is true and complete to the best of my knowledge. I acknowledge that The Kingsley Group operates a drug- and alcohol-free environment and agree to abide by all program rules and policies as a condition of continued residency.*

YesNo
Signature
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The Kingsley Group