Complete Program Intake Form
Name
First Name
Last Name
E-mail
*
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Gender (Assigned at Birth)
*
Please Select
Female
Male
Referral Source
Please Select
Hospital Social Worker
Community Agency
Case Manager
Self
When do you. need housing? (Move-in date)
-
Month
-
Day
Year
Date
Do you smoke?*
Please Select
YES
NO
Where are you currently residing?
Please Select
Homeless\ Shelter
Hospital
Prison
Rehab
DV Shelter
Family \Friend
Do you have any physical disabilities or mobility concerns?*
Please Select
Yes
No
If Yes, please provide more information on the line below
If you answered Yes above, please explain and provide more information on the line below?
Are you currently on probation or parole? If yes, please provide the name and contact information of your probation/parole officer:
Please Select
Yes
No
If you answered Yes above, please explain and provide more information on the line below?
Do you currently or have a history of using any illegal substances or misusing prescription medications? *
Please Select
YES
NO
If you answered Yes above, please explain and provide more information on the line below?
To maintain a stable environment, clients are required to contribute monthly to housing expenses. What is the client's current source of income?
Please Select
SSI
SSDI
HOUSING VOUCHER
EMPLOYMENT INCOME
ORGANIZATION / AGENCY SPONSOR
VETERAN BENEFITS
OTHERS
Our program offers safe, supportive shared housing in a drug- and alcohol-free environment, where each resident will have a roommate. Is the client open to living in a shared room?
Please Select
YES
NO
PRIVATE
Is there anything else you'd like us to know?
Should be Empty: