Housing Intake Form

Speak With Love Housing Program

Participant Intake & Enrollment Application

Date of Application

Date

Referral Agency or Referrer Name

Referral Agency or Referrer Phone

Full Name (First, Last)

Gender

Date of Birth

Date

Social Security Number Last 4 digits

Phone:

Email Address

example@example.com

Upload your copy of a valid picture ID

Emergency Contact Name

Emergency Contact Number, Email or Address

Relationship to Emergency Contact

Current Living Condition

Brief Summary of Situation/Reason for Housing Need

List the areas(cities) that you are open to moving to

Current Medical and or Mental Health Issues or Diagnosis (List Below)

Medical & Mental Health History (List Below)

Mental Health Diagnosis (if any)(List Below)

Are you a registered sex offender? (This doesn't affect your chance or being accepted into the program. It's for informational purposes only)

Are you currently on parole or probation? (If YES, then check the 'Other' box and list your Parole Officer's Name and Phone Number)

Other

I hereby authorize Speak With Love Foundation Corp. International, its representatives, and authorized partners to conduct a criminal background check for the purpose of determining eligibility, placement, participation, or continued involvement in housing-related services or programs.

Monthly Income Amount (if any)(We may ask for income verification)

What is your source of income (if any)

Any disabilities or special accommodations needed?

If YES, then explain. If No, then type NONE

Preferred Room Type

What is your monthly budget? How much can you afford to pay monthly?

Which group/s best describe you?

If you have children that will live with you, list their ages and gender and any mental or physical disabilities.

Independent Living & Functionality Acknowledgment

Our program is designed for individuals who are high-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 the following on your own:

Personal hygiene, grooming, meal preparation,eating, medication (unless managed by an outside provider), mobility, transportation arrangements, housekeeping, laundry and all 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?

If No, then please explain. If Yes, type Yes

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

If Yes, then list Agency or Caregiver Name and contact information or indicate if you need our assistance to find one

Do you have a support animal? (Documentation required to prove the animal is for medical support)

If Yes, type the type of animal. Be as detailed as possible. If No, then type NONE.

What's the earliest date you want to move in?

Date

Check the boxes below if you understand and agree:

I have read, understand and agree to abide by the house rules provided on the website and understand that house rules may be amended periodically to ensure that new issues are considered.

Program Agreement Preview

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 Signature or Initials

Date

FOR OFFICIAL USE ONLY:

Review Results

Reviewer Full Name

Signature

Date