Olives Branch Living – Housing Intake Form
Name
*
First Name
Last Name
Gender
*
Male
Female
Race
*
Caucasion
Black/ African American
Hispanic
Native American
Others
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have the permission to call the number above?
*
Yes
No
Best time to reach you?
*
Morning
Afternoon
Evening
Anytime
Emergency Contact Name
*
Emergency Contact Phone Number
*
Relationship to Emergency Contact
*
Back
Next
Housing History
Which best describe you?
*
Veteran
Domestic Violence Survivor
Recently Released from Incarceration
Experiencing Housing Instability
Seeking a Fresh Start with Support
In Recovery (Substance Use or Mental Health)
Other
How long have you been in this situation?
*
Client's Current Address
*
What is your current living situation?
*
Living with a friend
Living in a car
Shelter
Homeless
Hospital/ Facility
Shared Housing
Others
Reason for seeking Housing?
*
Have you ever been evicted?
*
Yes
No
If yes, please provide details
*
Back
Next
Background & Legal History
Are you currently on parole or probation?
*
Yes
No
If yes, please provide details (e.g. Probation Officer Full Name and Contact Information)?
*
Have you been convicted as a Sex Offender?
*
Yes
No
If yes, please provide details
*
Have you been convicted of a felony in the last 10 years?
*
Yes
No
If yes, please provide details
*
Are there any pending criminal charges against you?
*
Yes
No
If yes, please provide details
*
Have you ever been charged with a violent crime?
*
Yes
No
If yes, please provide details
*
Back
Next
Health & Support (Confidential)
Do you currently receive services from a caseworker, counselor, or community agency?
*
Yes
No
If yes, please provide details
*
Do you have any disabilities or special needs?
*
Yes
No
If yes, please provide details
*
Do you have any history of substance abuse?
*
Yes
No
If yes, please provide details
*
Do you have any medical conditions that require ongoing treatment or monitoring?
*
Yes
No
If yes, please describe your disabilities or special needs?
*
Do you take any prescribed medications?
*
Yes
No
If yes, please provide details
*
Do you have any mental health conditions?
*
Yes
No
If yes, please provide details
*
Do you have any mobility or accessibility needs (e.g., wheelchair access, stair limitations)?
*
Yes
No
If yes, please provide details
*
Back
Next
Employment & Income
Current Income Source
*
Employed
SSI/ SSDI
Retirement
Voucher
Organizational Funding
Others
Monthly Income Amount
*
Can you provide proof of income?
*
Yes
No
Do you have a representative payee?
*
Yes
No
If yes, please provide details
*
Back
Next
Housing Preferences
When does the client need to be placed?
*
-
Month
-
Day
Year
Date
Desired Length of Stay
*
Room Type Preferred
*
Shared Room
Private Room
No Preference
Do you have any concerns about living with others (e.g., age, gender, habits)?
*
Are you open to scheduled room inspections to maintain property standards?
*
Yes
No
Do you currently have furniture or personal belongings that will need space (Clients are only allowed 2 personal bags)?
*
Yes
No
If yes, please provide details
*
Back
Next
Agreement & Acknowledgment
Are you willing to follow house rules and expectations (e.g. no smoking in house, no unapproved guests, quiet hours, cleanliness)?
*
Yes
No
Are you able to live independently without daily assistance?
*
Yes
No
I understand this is an independent living program, not assisted living.
*
Yes
No
Olives Branch Living is a drug- and alcohol-free environment. Do you agree to follow this policy?
*
Yes
No
I acknowledge that participation is based on month-to-month terms and ongoing compliance with program guidelines.
*
Yes
No
I agree to pay rent on time as outlined in my housing program agreement.
*
Yes
No
I agree to follow all house rules and understand repeated violations may result in termination of my housing.
*
Yes
No
I acknowledge that Olives Branch Living is not liable for my personal belongings.
*
Yes
No
I certify that the information I have provided is accurate and truthful to the best of my knowledge.
*
Yes
No
How did you hear about Olives Branch Living?
*
Yes
No
How did you hear about Olives Branch Living?
*
Referral
Social Media
Google
Flyer
Others
Typed Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Back
Submit
Next
Next Steps After Submission
Thank you for your interest in Olives Branch Living. Our current housing rates are based on room type and location. Rates start at $750/month for shared accommodations. Once your application is reviewed, a member of our team will contact you to discuss availability, pricing, and next steps. Please note: This form adds you to our priority interest list and current waitlist. Placement is offered based on availability, program fit, and the order in which applications are received.
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