Graceful Steps Housing
Supportive Housing Intake Assessment
Client Information
Client Full Name
*
First Name
Last Name
Birth Date
Please select a month
January
February
March
April
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December
Month
Please select a day
1
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Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
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2015
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2012
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1925
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1923
1922
1921
1920
Year
Sex at Birth
*
Female
Male
Race
*
Asian
Black
Caucasian
Hispanic
Other
Refuse
Preferred Phone Number
*
E-mail Address
example@example.com
Do you have children that are joining the program with you? (If yes, how many?)
*
Please Select
No
Yes
Yes; 1 Child
Yes; 2 Children
Yes; 3 Children
Yes; 3+ Children
Emergency Contact Full Name
First Name
Last Name
Emergency Contact Phone Number
Emergency Contact Relationship to Client:
Representative Name (if applicable)
First Name
Last Name Initial
Representative Organization (if applicable)
Current Living Situation
Select all that apply.
Homeless
Transitional Housing
Jail/Prison Release
Hospital/Rehab
Senior
Brief Summary of Reason for Housing Need:
Referral Source (if applicable)
Self
Agency
Parole/Probation
Hospital or Treatment Center
Family/Friend
Medical History
Please list any relevant medical history including allergies:
(Include mental health history if any)
Do you have any mental health diagnosis?
*
Please Select
Yes
No
Do you have any mental health diagnosis that are untreated?
Please Select
Yes
No
Are you recovering from drug or alcohol addiction?
*
Please Select
Yes, Alcohol
Yes, Drugs
Yes, Both
None
Substance use history (if any)
Please Select
Alcohol
Drugs
None
Legal Background
Do you have a criminal record?
*
Please Select
Yes
No
This does not disqualify you from the program.
Are you currently on probation or parole?
*
Please Select
Yes
No
This does not disqualify you from the program.
Are you a registered sex offender?
*
Please Select
Yes
No
This does not disqualify you from the program.
Income Information
Do you have a source of income?
*
Please Select
Yes
No
What is the source of income?
*
Please Select
Yes
No
Income amount (if any)
Housing Preferences
Are you comfortable living in a shared environment?
*
Please Select
Yes
No
Preferred room type
*
Please Select
Shared
Private (If available)
Do you require first-floor housing or have restrictions with stairs?
*
Please Select
Yes
No
Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?
*
Please Select
Yes
No
Do you currently have or need a home health care provider or outside support service?
*
Please Select
Yes
No
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Do you require short-term or long-term housing?
*
Please Select
Yes
No
Will you require any wheelchair-accessible features, mobility assistance, or other accommodations?
*
Please Select
Yes
No
Independent Living & Functionality Acknowledgment
Our program is designed for individuals who are 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 24/7 in person supervision. You must be able to manage your own: Personal hygiene and grooming ; Meal preparation and eating ; 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.
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.
*
Yes, I understand.
No, I do not understand.
If selected for the program do you consent to fully comply with all program policies and house rules at all times?
*
Please Select
Yes
No
Select all of the services you are requesting
Job Placement
Apply for SNAP benefits
Apply for SSI/SSDI
Organizational Payee
Health Insurance Enrollment
Clothing Donation
Cellphone/Tablet Assistance
Life Skills
Desired move in date:
*
-
Month
-
Day
Year
Date
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Signature
*
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
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