WHELP Housing Intake Form

Representative Organization (if applicable)

Select all that apply*

Brief Summary of Reason for Housing Need:

Referral Source (if applicable)

Please list any relevant medical history including allergies:

Desired Move in Date

Date

Please read the following carefully. By signing this form, you acknowledge your understanding and agreement to terms and conditions of participation in the WHELP Housing Program. Please be advised this does not serve as program acceptance.

Participation in the WHELP Housing Program is subject to eligbility critera including income and ability to live independently. Participant must be able to live with or without minimal support,or with support from outside providers.

Admission is not guaranteed and is based on the availibility of beds. Participants are always added to the wait-list (if no beds are available). Which are picked on a first come, first serve basis.

All personal information collected is confidental and used soely for the purpose of determining eligibility, providing services, and maintaining program records.

WHELP Housing Program complies with all applicable privacy laws. Information may be shared with authorized service providers (Social Worker, Probation/ Parole Officer, Power of attorney, etc)

Signature of Participant or Person completing form on their behalf*

Do you have any mental health diagnosis? *

Do you have any mental health diagnosis that are untreated? *

Are you recovering from drug or alcohol addiction? *

Substance use history (if any)

Do you have a criminal record?*