Housing Intake Form

Speak With Love Housing Program

Participant Intake & Enrollment Application
Date of Application*

MonthDayYear
Date
Referral Agency or Referrer Name
Referral Agency or Referrer Phone
Full Name (First, Last)*
Gender*
Date of Birth*

MonthDayYear
Date
Social Security Number Last 4 digits
Phone:
Email Address
example@example.com
Emergency Contact Name
Emergency Contact Number, Email or Address
Relationship to Emergency Contact
Current Living Condition

Couch SurfingStaying With OthersTransitional HousingHospital or Treatment CenterHomeless
Brief Summary of Situation/Reason for Housing Need
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)

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

NOOther
Monthly Income Amount (if any)
What is your source of income (if any)
Any disabilities or special accommodations needed?

YESNO
If YES, then explain:
Preferred Room Type

Private ($$)Shared ($)
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?

YESNO
If No, then please explain
Do you currently have or need a home health care provider or outside support service?

YESNO
If Yes, then list Agency or Caregiver Name and contact information or indicate if you need our assistance to find one
What date do you want to move in?

MonthDayYear
Date
Check the boxes below if you understand and agree:

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.
Program Agreement Preview

I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins. I acknowledge that violating rules may result in a strike or dismissal from the program.
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

Clear
Date

MonthDayYear
Date
FOR OFFICIAL USE ONLY:
Review Results

Applicant AcceptedApplicant Denied
Reviewer Full Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: