Program Intake Application

Supportive Housing Intake Form

Please complete all fields and ensure that all information is accurate to join our waitlist.
Client's Name

First NameLast NameSuffix
Birth Date

MonthDayYear
Gender
Race
E-mail Address
example@example.com
Client's Phone Number
Format: (000) 000-0000.
Do we have permission to contact you at the phone number provided?
What is your rooming preference?
What is your ideal intake date?

MonthDayYear
Date
What is your current living situation?

Other
How will you pay your program fees?

Other
What is your monthly income? If you do not currently receive monthly income please put "0.00".
Do you have a disability? If yes, please explain your disability below. If no, type NONE.
Do you require a handicap accessible living environment?
Are you an ex-offender?
Are you currently on probation or parole?
Are you able to independently perform daily living activities?
Have you ever been convicted of a violent crime?
Are you a convicted sex offender? (Your answer does not disqualify you from our program)
Do you need help recovering from drugs/alcohol?
Do you suffer from any mental illnesses? If yes, please list your diagnosis and medication below. If no, type NONE.
Select all of the services you're interested in.
Emergency Contact / Representative

First NameLast Name
Emergency Contact / Representative's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What is the relation of the emergency contact and the applicant?
How did you hear about us?
Should be Empty:

Supportive Housing Intake Form