Client Intake form
Personal Information (FOR ADULTS ONLY)
1. Name
*
First name
Last Name
2. Date Of Birth (MM/DD/YYYY)
*
-
Month
-
Day
Year
Date
3. Gender
*
Male
Female
4. Phone Number
*
Please enter a valid phone number.
5. Email
*
example@example.com
6. Emergency Contact Name/Phone
Full Name
Phone Number
7. Do you have proof of ID?
*
Yes
No
Upload ID
*
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Background Information
Current Living Situation
*
Homeless
Shelter
With Family/Friends
Facing eviction
Displaced
Transitional
Other
Do you have any Kids? (At this moment, we can only accept ADULTS 18+ only )
*
Yes
No
How long have you been in this situation?
Do You have any Pets?
*
Yes
No
Have you Lived in Independent housing before?
*
Yes
No
Do you understand that you will be living in a shared space?
*
Yes
No
On a scale of 1–5, how comfortable are you living in a shared community? (1 = not comfortable, 5 = very comfortable
*
Are you comfortable sharing Shared spaces with other individuals? (Bathroom, living room, kitchen, etc.)
*
Yes
No
Pathway Homes ONLY offers independent living. We are not a licensed group home or treatment center. Do you understand that will be living with other independent Individuals?
*
Yes
No
Are you currently employed?
*
Yes
No
Do you receive any benefits or assistance? (SSI, SSDI, VA, Food Stamps, etc.)
*
Yes
No
Are you able to submit proof of income?
*
Yes
No
Monthly Income (if any):
How do you plan on ensuring timely payments each month?
What is your monthly budget each month for payments?
*
Are you a registered Sex Offender?
*
Yes
No
Are you on Probation/Parole ?
*
Yes
No
If yes, Please provide probation/Parole officer contact
Are you a US veteran?
*
Yes
No
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Pathway Questionnaire
Do you smoke or use tobacco?
*
Yes
No
Do you use alcohol or drugs?
*
Yes
No
Do you have a history of substance use?
*
Yes
No
Do you have any medical conditions we should be aware of?
*
Yes
No
If yes, please explain:
Do you have any physical or mobility disabilities?
*
Yes
No
If yes, please explain
Do you have any mental health diagnosis?
*
Yes
No
Are you currently taking any medication?
*
Yes
No
If yes, please list:
Are you currently receiving case management or social services?
*
Yes
No
If yes, which agency?
What type of room are you interested in?
*
Shared Room
Private Room
How long do you anticipate on needing housing support
*
3 months or less
3-6 months
6-12 months
1 year+
Do you prefer a social or quiet environment?
*
Social
Quiet
Both
How soon do you need housing?
*
Are you comfortable with following house rules?
*
Yes
No
If given responsibilities in the house (chores, cleanliness, etc.), how willing are you to participate? (1–5 scale)
*
How do you handle conflict?
What Room Are you interested in? (Select all that apply)
*
$750 Shared room (Shared bathroom with 1-2 Individuals)
$800 Shared room (Shared Bathroom with 1-2 Individuals, Larger space)
$800 Shared Master room (Shared Bathroom with 1 Individual, master bedroom)
$950 Private Room (Tv, Mini fridge, Shared Bathroom with 1-2 Individuals)
$1000 Private Room (Tv, Mini fridge, Shared bathroom with 1 Individuals)
$1600 Master room( Tv, Mini fridge, Love seat, two sinks, can split rent with another person)
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