Shared Living Intake Questionnaire
Complete form to join our waitlist:
Today's Date
*
-
Month
-
Day
Year
Date
Applicant's Name
*
First Name
Middle Name
Last Name
Applicant's Email
*
example@example.com
Applicant's Phone Number
*
Please enter a valid phone number.
Do we have permission to text/leave a message on the number provided?
*
Yes
No
Applicant's Date of Birth
*
-
Month
-
Day
Year
Date
Applicant's Current Age
*
Does applicant possess a current State ID or Driver's License?
*
Yes
No
Does applicant possess a Social Security Card or copy of card?
*
Yes
No
Last 4 Digits of Social Security Number
*
Applicant's Gender At Birth
*
Female
Male
Gender Applicant Currently Identifies As
Female
Male
Nonbinary
Transgender Female
Transgender Male
Applicant's Race
*
American Indian/Native American
Asian
Black or African American
Caucasian
Hispanic
Islander
Other
Applicant's Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Is English application's first language?
*
Yes
No
If answered "No" what is applicant's first language?
Applicant's Emergency Contact
First Name
Last Name
Emergency Contact Relationship
Parent, Sibling, Relative, Friend, etc
Emergency Contact Phone Number
Please enter a valid phone number.
Who is completing this form?
*
Self
Representative/Agent
Representative/Agent Name
First Name
Last Name
Representative/Agent Organization (ex: United Way, VA, Facility, etc)
Representative/Agent Email
example@example.com
Representative/Agent Phone Number
Please enter a valid phone number.
When does the applicant need to be placed?
*
-
Month
-
Day
Year
Date
Applicant's Current Living Situation
*
Hospital / Facility
Incarcerated
Shared Housing / Group Home
Living with a friend or family
Living in a vehicle
Living in a hotel / motel
Living in a shelter
Living on the street / unhoused
Applicant's Current Location Name
(If applicable list business/facility name)
Applicant's Current Location Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant's Previous Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does applicant understand this is a shared living home?
*
Yes
No
Has applicant lived in shared housing before?
*
Yes
No
Does applicant agree to sharing a room with at least one (1) other individual?
*
Yes
No
Is the applicant willing to follow strict house rules? ( No guests, no drugs, no alcohol, no pets, clean space, curfew, etc.)
*
Yes
No
Does applicant understand this a month-to-month housing program and fees must be paid on time to maintain their housing?
*
Yes
No
Does applicant vapor or smoke?
*
Yes
No
Program homes are non-smoking with no exceptions. Applicant is allowed to smoke/vape outside in the designated areas. Does applicant understand our program does not allow smoking/vaping inside our homes?
*
Yes
No
How long would the applicant want to be apart of our housing program?
*
1 to 2 Months
3 to 6 Months
7 to 12 Months
13 or More Months
Is applicant an US Military Veteran?
*
Yes
No
How will applicant pay for housing?
*
SSI
SSDI
Retirement
VA Benefits
Organization Funding
Job
Other
How much income does applicant receive monthly? (If none type "NONE")
*
Is applicant currently employed?
*
Yes
No
Employer Name
Applicant's primary mode of transportation?
*
Public Transportation
Transportation Service
Personal Car
Is applicant able to pay a monthly program base fee of $750 plus a small program entry fee? (Actual program fee amount is assessed individually)
*
Yes
No
Does applicant have any allergies, medical conditions, or anything we should be aware of?
*
Yes
No
If "Yes", please explain
Does the applicant suffer from mental illness?
*
Yes
No
If answered "Yes", list mental illness diagnoses
Do applicant currently take any medications?
*
Yes
No
If answered "Yes", list medications.
Is applicant disabled?
*
Yes
No
If answered "Yes" list disability(s)
Does applicant require an accessible living environment?
*
Yes
No
If answered "Yes" please explain
Is applicant able to preform ADLs (Activities of Daily Living) unassisted?
*
Yes
No
Does applicant have an animal that will be living with them?
*
Yes
No
If "Yes" please specify the category of the animal. (Documentation is required and will be verified)
Service Animal
Emotional Support Animal (EAS)
If "Yes" list type and description of animal.
(ex: cat, dog, bird, weight, breed, etc)
Will applicant having children living with them?
*
Yes
No
Is applicant an ex-offender? (Answering "Yes" does not automatically disqualify applicant from the housing program)
*
Yes
No
If "Yes", when, and what were applicant's charge(s)?
Does applicant have any outstanding warrants or pending criminal charges? (Answering "Yes" does not automatically disqualify applicant from the housing program)
*
Yes
No
If "Yes" list the estimated date of the warrant/pending charges and the nature of the warrant/charges
Is applicant currently on Probation or Parole?
*
Neither
Probation
Parole
Has applicant been convicted as a Sex Offender? (The answer to this question does not automatically disqualify them from the housing program)
*
No
Yes with 1,000 ft Restriction
Yes without 1,000 ft Restriction
Does applicant need help with recovering from Opioid(s) and/or other drugs and alcohol?
*
Yes
No
Does applicant receive support from a case/social worker, family member, or program?
*
Yes
No
Does applicant agree to an in-person assessment of ADLs (Activities of Daily Living) prior to being accepted into the housing program?
*
Yes
No
Please select any assistance applicant may need from the choices below:
Transportation Assistance
Apply for SNAP benefits
Apply for SSI/SSDI
Organizational Payee
Apply for Representative Payee
Health Insurance Enrollment
Home Healthcare Service
Clothing Donation
Cellphone/Tablet Assistance
Group Therapy
Day Program
Life Skills/Recovery Groups
How did you hear about us?
*
Referral from Agency, Hospital, Social Worker, Parole/Probation, etc
Search Engine/Internet
Social Media
Word of Mouth
If you were referred please list person's and/or organization's name
Anything you would like us to know?
"By clicking submit I and/or my representative/agent understand that if I and/or my representative/agent have deliberately given any false information or have withheld any information regarding any situation, I will be immediately dismissed from the housing program and the no refund policy applies". Program rules are strictly enforced.
Submit
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