Form
Bloom Oasis - Housing Intake Assessment
Welcome to Bloom Oasis!Thank you for your interest in our independent living home, where serenity and strength blossom. We are dedicated to creating a supportive, peaceful environment for our residents.Please complete this intake form to help us learn more about you or your loved one. All information provided will be kept confidential.If you have any questions, please contact us at 470-764-5007 or info@bloomoasis.com.
Member Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender Identity
*
Male
Female
Race/Ethnicity
*
Black or African American
White
Hispanic or Latino
Asian
Native American or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
Member Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Do we have permission to call/leave a message on the number provided?
*
Yes
No
Emergency Contact Name
*
Emergency Contact Phone Number
*
What best describes you?
*
Veteran
Domestic Violence Survivor
Recently Released from Incarceration
Experiencing Housing Instability
Seeking a Fresh Start
Other
Are you receiving consistent financial support or income?
*
Yes
No
Source of income and monthly amount?
*
Can you provide proof of income?
*
Yes
No
Do you have a representative payee?
*
Yes
No
If yes, please provide details.
*
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Current Housing Information
What is your current living situation?
*
Living with a friend
Living in a car
Living in a shelter
Homeless
Hospital/Facility
Shared Housing
Other
How long have you been in this situation?
*
What are the main reason(s) you're seeking housing now?
*
Have you previously lived in a supportive transitional living program?
*
Yes
No
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Health & Wellness Information
Do you have any mobility or accessibility needs (e.g., wheelchair access, stair limitations)?
*
Yes
No
If yes, please explain.
*
Do you have any known medical conditions we should be aware of?
*
Yes
No
If yes, please explain.
*
Do you currently receive support for mental health or emotional wellness?
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Yes
No
If yes, please explain
*
Have you ever been hospitalized for a mental health concern?
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Yes
No
If yes, please provide details
*
Are you open to supportive services if needed (counseling, case management.)?
*
Yes
No
Are you currently taking any prescribed medications?
*
Yes
No
If yes please provide details.
*
Do you have any history of drug or alcohol use? (This will not disqualify you from our program & services)
*
Yes
No
If yes, please explain
*
Are you currently in recovery?
*
Yes
No
Clean/Sober since?
-
Month
-
Day
Year
Date
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Accountability History
Are you currently on probation or parole
*
Yes
No
If yes, please explain.
*
Have you had any past charges or convictions involving violence"
*
Yes
No
If yes, please explain.
*
Do you have any active warrants
*
Yes
No
Have you been convicted as a Sex Offender?
*
Yes
No
Have you been convicted of a felony within the last 10 years
*
Yes
No
If yes, please explain.
*
Are there any pending criminal charges against you?
*
Yes
No
If yes, please explain.
*
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Hope, Goals & Assistance
What are your short term goals?
*
When do you or client need to be placed?
*
What is the desired length of stay?
*
Room type preferred?
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Shared Room
Private Room
Do you have concerns about living with others? (e.g. age, gender, habits)
*
Are you open to room inspections to maintain property standards?
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Yes
No
Are you willing to follow house rules and expectations?
*
Yes
No
Bloom Oasis is a drug and alcohol free environment. Do you agree to follow this policy?
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Yes
No
I acknowledge that Bloom Oasis is designed for individuals capable of living independently and not offer assisted living care?
*
Yes
No
What type of support would help you thrive in your independent living journey at Bloom Oasis?
*
I understand participation is month-to-month and depends on following program guidelines.
*
Yes
No
I agree to uphold financial responsibilities as outlined in the housing program terms.
*
Yes
No
I acknowledge that compliance with Bloom Oasis guidelines is required, and repeated non compliance may lead to discharge from the program.
*
Yes
No
I acknowledge that Bloom Oasis is not liable for any personal belongings.
*
Yes
No
I acknowledge that Bloom Oasis reserves the right to update program rules as needed.
*
Yes
No
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Acknowledgement of Terms & Participation
I understand the information I've submitted is true and complete to the best of my ability and understand this is a pre-screening form for housing eligibility.
*
Yes
No
Signature
*
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Who Connected You With Bloom Oasis?
How did you hear about Bloom Oasis?
*
Referral
Social Media
Goodle
Flyer
Other
Submit
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