TrueCourse Intake Form

TrueCourse Intake Form
Section 1: Personal Information
Full Name *

First NameLast Name
Date of Birth *

MonthDayYear
Date
Gender *

FemaleMaleTransgenderOther
Marital Status *

SingleMarriedDivorcedWidowed
Phone Number*
Please enter a valid phone number.
Email Address
example@example.com
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone Number *
Social Security Number (SSN): Your Social Security (SSN) is required solely for the purpose of conducting a background check to verify eligibility for housing. *
Section 2: Housing & Background
What best describes you? (Select all that apply) *

VeteranDomestic Violence SurvivorIn Recovery (Substance or Mental Health)Recently Released Form IncarcerationExperiencing Housing InstabilitySeeking a Fresh Start
What is your current living situation? *

Living with friendsLiving in carShelterHomelessHospital/FacilityShared HousingOther
Would you be able to provide and verify proof of income? *

YesNo
Monthly Income *
How do you plan to pay monthly rent? *

WeeklyBiweeklyMonthly
Can you provide proof of identity? (Valid License or State ID) *

YesNo
Upload Photo ID*

Cancelof
Do you have Insurance *

YesNo
Are you currently working with any case manager,social worker,or re-entry program? *

YesNo
If yes, please provide name and organization
We are currently housing single adults with income. At this time, we cannot house children, couples,or pets. Do you qualify as a single adults? *

YesNo
Are you open to living in a shared housing environment with other? *

YesNo
How soon are you wanting to move in? *
Are you able to live independently without daily assistance? *

YesNo
Do you have any physical disabilities that require accommodations? *

YesNo
Do you currently take any prescribed medications? *

YesNo
Please list any mental health conditions that you are currently managing (e.g., depression,anxiety,PTSD,bipolar disorder) *
Have you ever been hospitalized for mental health reasons? *

YesNo
Do you have a history of substance abuse? (Select all that apply) *

AlcoholDrugsNone
Do you use any tobacco products? *

YesNo
Are you currently on parole or probation? *

YesNo
Are you a registered sex offender?*

YesNo
Section 4: Program Readiness & Anknowledgements
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 on your own.
- Physical and personal hygiene and grooming
- Meal prep and eating
- Medication (must be managed by an outside provider)
- Mobility and tranportation arrangements
- Housekeeping and laundry
- Daily living responsibilites
If you require medical or personal care services,they must be provided by a licensed outside agency or caregiver arranged and paid for separately.
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.

TrueCourse Intake Form

Section 1: Personal Information

Section 2: Housing & Background

Section 4: Program Readiness & Anknowledgements