Supportive Housing Intake Assessment
Enrollment Application
Client Information
Client Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Sex at Birth
*
Male
Female
Race
*
Asian
Black/ African American
Caucasian
Hispanic
Other
Preferred Phone Number
*
Please enter a valid 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.1
Yes,2
Yes,3
Yes, 3+
Emergency Contact Full Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Relationship to Client:
Representative Name (if applicable)
First Name
Last Name or Last Name Initial
Representative Organization (if applicable)
Current Living Situation
Select all that apply
*
Homeless
Senior
Veteran
Domestic Violence Survior
Transitional Housing
Jail/Prison Release
Hospital/ Rehab Discharge
Brief Summary of Reason for Housing Need:
Tell me about yourself:
Referral Source (if applicable)
Self
Agency
Parole/Probation
Hospital or Treatment Center
Family Friend
Do you have a valid ID/Driver’s License?
*
Please Select
If no, we will assist with obtaining one.
Do you have a copy of your birth certificate?
*
Please Select
If no, we will assist with obtaining one.
Do you have a copy of your birth social security card?
*
Please Select
If no, we will assist with obtaining one.
Do you have any mental health diagnosis?
*
Please Select
Yes
No
Medical History
Please list any medical history including allergies:
(Include mental health history if any)
Please list any medication(s) you currently take:
(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
No
Yes, Drugs
Yes, Alcohol
Yes, Drugs + Alcohol
Substance use history (if any)
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 your source of income?
*
Please Select
SSI
SSDI
Employment
Private Pay
Other
Monthly income amount (if any):
*
Housing Preferences
Will you require any wheelchair-accessible features, mobility assistance, or other accommodations?
*
Please Select
Yes
No
Preferred room type
*
Please Select
Shared
Private (if available)
Are you comfortable living in a shared environment?
*
Please Select
Yes
No
Do you require short-term or long-term housing?
*
Short-term
Long-term
Unknown
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
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 Preparation/ Job Placement Assistance
Apply for SNAP benefits
Apply for SSI/SSDI
Clothing Donation
Organizational Payee
Health Insurance Enrollment
Cell Phone/Tablet Assistance
Life Skills
Desired move in date
*
-
Month
-
Day
Year
Date
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.
*
First Name
Last Name
Submit
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