Hope Haven 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
*
-
Area Code
Phone Number
E-mail Address
example@example.com
How many people are in your family unit and joining the program with you?
*
Please Select
Myself only
2
3+
Emergency Contact Full Name
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
Emergency Contact Relationship to Client:
Representative Name (if applicable)
First Name
Last Name
Representative Organization (if applicable)
Current Living Situation
Select all that apply
*
Homeless
Senior
Veteran
Domestic Violence Survivor
Transitional Housing
Jail/ Prison Release
Hospital/ Rehab Discharge
Brief Summary of Reason for Housing Need:
Do you have a valid ID/Driver’s License?
*
Please Select
Yes
No
If no, we will assist with obtaining one.
Do you have a copy of your birth certificate?
*
Please Select
Yes
No
If no, we will assist with obtaining one.
Do you have a copy of your birth social security card?
*
Please Select
Yes
No
If no, we will assist with obtaining one.
Medical History
Please list any medical history including allergies:
(Include mental health history if any)
Do you have any mental health diagnosis?
*
Please Select
Yes
No
Are you prescribed any medications related to that diagnosis?
*
Please Select
Yes
No
Legal Background
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
What is your source of income?
*
Please Select
SSI
SSDI
Employment
Private Pay
Other
Monthly 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)
Will you require any wheelchair-accessible features, mobility assistance, or have restrictions with stairs?
*
Please Select
Yes
No
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.
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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