The Haven Quarters - Application

The Haven Quarters - New Resident Intake Form

Creating a safe and supportive place to rebuild with dignity and purpose

Applicant Information

First Name

Last Name

Phone

Format: (000) 000-0000.

Date of Birth

Date

Applicant Current Address

Current Address

Street Address Line 2

CityState

ZIP Code

Email

example@example.com

Gender Identity

Emergency Contact Full Name

Relationship

Emergency Contact Phone

Format: (000) 000-0000.

Emergency Contact Address

Address

Street Address Line 2

CityState

ZIP

Do you grant The Haven Quarters permission to contact Emergency Contact? Yes/No

Do you have any physical disabilities? If yes, please specify.

Do you depend on health care staff to provide daily care services? If yes, please provide company name.

History of violence or aggression. If yes, please explain.

Registered sex offender? If yes, explain.

Felony convictions? If yes, explain.

If you have had a Felony convictions please provide date of most recent conviction

History of alcohol or drug use? If yes, describe?

Date of last use

Date

Longest period of sobriety?

Past treatment or recovery programs completion date?

Date

Do you have a history of mental illnesses or been diagnosed with a mental disorder?

Current medications including for mental illness?

Ever been evicted If yes explain

Do you smoke?

Do you have a valid ID?

Income & Resources Benefits/Supports Received (SSI, SSDI, SNAP, employment)

Benefits Supports Received? If yes tell all that apply. Ex: SSI SSDI Food Stamps TDAP etc

Do you have income? If yes, how much and the dates.

Currently employed? If yes, where? Can you provide proof?

Hours per week

How do you plan to pay for housing? Are you able make on-time monthly payments starting at $550 - $950 a month?

Describe your personality. social quiet etc

Cleanliness level Tidy Average Messy

Allergies of any kind? food, pets etc

Anything else youd like us to know

Referred By Agency or Individual

Agency Phone Number

Format: (000) 000-0000.

Signature

Date