HeRise Growth Center Intake Form

HeRise Growth Center Intake Form

Intake Inquiry form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medicaid #
Medicaid Provider
Additional
Helpful information to help with your case
Email
example@example.com
Phone Number

Area CodePhone Number
Eligibility & Background
Are your currently receiving any other support or services?

YesNo
If so, please specify.
Are you currently incarcerated?

YesNo
Have you been sentenced?

YesNo
When is your next court date?
Do you need a letter of recommendation for court?
Do you have Employment?
Do you need Transitional Housing with HeRise Growth Center?
Our Transitional Housing Facility is in Md
What was your criminal charges for?
How many times have you been convicted of a crime?
Are you actively seeking employment or entrepreneurship opportunities?

YesNo
Briefly describe your goals for participating in HeRise Growth Center:
Skills & Interests:
What skills or talents do you possess?
Highest Level of Education
What area are your most interested in developing? (housing, entrepreneurship, finance, education, etc.)
Do you have special needs or accommodations?

YesNo
If yes, please specify:
please type n/a if you don't have any special needs
Are you currently enrolled in any educational programs?

YesNo
If yes, please specify:
Do you feel confident in your basic reading, writing, and math skills?

YesNo
If no, which areas would you like to improve?
Life Skills Knowledge
How comfortable are you with managing daily responsibilities such as cooking, cleaning, and time management?
Do you have experience with setting and achieving personal goals?

YesNo
Are you familiar with basic problem-solving and decision-making skills?

YesNo
Do you need support with communication and conflict resolution?

YesNo
Financial Literacy
Are you familiar with budgeting and managing personal finances?

YesNo
Do you understand how credit works, including credit scores and loans?

YesNo
Do you have experience saving money or financial planning?

YesNo
Are you interested in learning about starting a small business or entrepreneurship?

YesNo
Do you have a preferred area of focus?

Education & Skill BuildingFinancial Literacy & PlanningEntrepreneurship & Business DevelopmentHousing & Living StabilityPersonal Development & Life SkillsOther
Mental Health
Do you take Medication?
If so, what is the medications prescribed?
When was your last mental health evaluation?
Do you have any mental health or behavioral health concerns that should be addressed?
Emergency Contact
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
*CASE MANAGERS MAY CALL FROM UNKNOWN NUMBERS.
HeRise Halfway house is NOT YET open however we are still providing help with housing referrals, mental health support, trade training, employment training and job opportunities.

Please attach letters of support to Help HeRise get open and government funding by December 2025.
Should be Empty:

HeRise Growth Center Intake Form

Eligibility & Background

Skills & Interests:

Life Skills Knowledge

Financial Literacy

Mental Health

Emergency Contact