Assessment

Unyque Is Paradise LLC. Participant Intake & Enrollment Application

Date of Intake

Date

Referral Agency Name of Referrer

Participant Information Full Name:

Full Name

Date of Birth

Date

Age

Social Security Number Last 4 digits

Phone Number

Email Address

example@example.com

Emergency Contact Name: Relationship: Emergency Contact Phone: Current Living Situation

Emergency Contact Name

Relationship

Current Living Situations:

Homeless

Couchsurfing/ Staying with others

Transitional Housing

Jail/Prison Release

Hospital/Rehab

Others:

Referral Source (If Applicable)

Other

Referring Contact Name

Family/ Friend Referring Contact Name

Phone/Email

Brief Summary of Situation Reason for Housing Need

Mental health diagnosis (if any):

Substance use history (if any)

Drugs If yes, explain:

Legal Background Are you currently on parole or probation?

List PO Name/ Phone Number:

Medical Mental Health History List Below

If yes explain

Are you a registered sex offender?

SSDI /SSI/ Employment Monthly Income Amount (if any):

Do you have a source of income?

Housing Preferences or Needs Any disabilities or accommodation needed?

Shared Rooms & or Private Room (if available)

Independent Living & Functionality Acknowledgment

Our program is designed for individuals who are highly functioning and capable of living independently. This is not a personal care home, nursing home, or assisted living facility. We do not provide medical care, personal assistance, or supervision. You must be able to manage your own: Personal hygiene and grooming Meal preparation and eating as well as Medication (unless managed by an outside provider) Mobility and transportation arrangements Housekeeping and laundry Daily living responsibilities. If you require medical or personal care services, they must be provided by a licensed outside agency or caregiver, arranged and paid for separately.

Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?

Do you currently have or need a home health care provider or outside supportservice?

I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing.

Participant Initials:

Participant Name

Date

Program Agreement Preview

I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program- related check-ins.

I acknowledge that violating rules may result in a strike or termination from the program. Applicant Declaration I certify that the above information is true to the best of my knowledge. I understand that this intake does not guarantee placement, and my application will be reviewed by staff.

Participant Name

Participant Signature

Date

Staff Name

Signature

Date

Participant Name