Pathway to Change

Pathway to Change

Resident Intake Form
Full Legal Name

First NameLast Name
Date of Birth (MM/DD/YYYY)

MonthDayYear
Gender:

MaleFemale
Phone Number:
Please enter a valid phone number.
Email Address:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact Name:

First NameLast Name
Relationship to You:

FamilyCousin/NephewsBrother/Sister
Emergency Contact Phone:
What is your primary reason for seeking housing? (Check all that apply)

Reentry from incarcerationAging out of foster careSenior housingRecovery housing (sobriety support)Veteran housingHomelessness/unstable housingOther
Desired Move-in Date:

MonthDayYear
Room Preference:

Private RoomShared RoomNo Preference
Have you lived in a shared housing program before?

YesNo
Are you currently on probation or parole?

YesNo
Do you have any pending legal matters?

YesNo
Are you currently employed?

YesNo
Are you currently enrolled in a support or recovery program?

YesNo
Do you have any allergies?

YesNo
Are you currently taking any medications?

YesNo
Do you have any physical or mobility limitations?

YesNo
Do you have any mental health conditions we should be aware of?

YesNo
What is your primary source of income?

EmploymentSSI/SSDIVeteran BenefitsOther
Payment Preference:

WeeklyMonthly
Can you pay the required deposit and first rent payment at move-in?

YesNo
How did you hear about Pathway to Change?

Case ManagerParole OfficerOnlineFriends/FamilyOther
Case Manager/Social Worker Name (if any):
Case Manager/Social Worker Phone:
Please enter a valid phone number.
Do you agree to follow all house rules and program policies?

YesNo
Do you consent to a background check if required?

YesNo
Do you give permission for us to share necessary information with partner agencies for your support?

YesNo
Applicant Signature:

Powered by Jotform SignClear
Staff Use Only – Approved

DeniedWaitlist
Date

MonthDayYear
Date
Should be Empty: