KindWell Living Intake Form

KindWell Living Solutions Participant Intake & Enrollment Application

Please complete this form to the best of your ability. Your information will help us determine eligibility and match you to the right housing opportunity. Submission does not guarantee housing.
1. Date and Referral Information
Date of Intake*

MonthDayYear
Date
Referral Agency Name of Referrer
Referral Source
2. Participant Information
Name*

First NameLast Name
Identification*

Cancelof
Tell Us About You.*
Date of Birth*

MonthDayYear
Date
Age*
Last 4 of SSN*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Gender*

MaleFemalePrefer not to Answer
Do you have children who will need to live with you?*

YesNo
Ages
type N/A if none
Emergency Contact Name*
Emergency Contact Phone Number*
Realtionship to You*
3. Current Living Situation
Please describe your current housing situation and reason for applying*

HomeslessCouch SurfingHospitalRehabOther
If Other please explain
4. Brief Summary of Situation
Please describe your current housing situation and reason for applying**
5. Medical & Mental Health History

Please be honest about your circumstances.
List any medical or mental health conditions*
If non type N/A
Mental health diagnosis*
if none type N/a
Substance Use History*

DrugsAlcoholNone
If any substance abuse history please explain*
If none type N/A
6. Legal Background

Please be honest about your circumstances. Dishonesty is immediate grounds for denial.
Are you on Probation or Parole?*

YesNo
If Yes, Please explain*
If no type N/A
Officer Name*
If none type N/A
Officer Number*
If non type N/A
Are you a registered Sex Offender?*

YesNo
If Yes explain.*
If non type N/A
7. Income Information
Do you have a source of income?*

YesNo
Income Type*

SSISSDIEmploymentOther
If Other Describe
Monthly Income Amount*
Income Verification*

Cancelof
8. Housing Preferences
Any Disabilities or accomodations needed*

YesNo
If Yes explain
If none type N/A
Preferred Room type*

Private RoomSemi-Private Room (Shared Occupancy)
Community Fee - A one-time Community Fee of $275 is required at the time of Move-in. This fee helps cover administrative processing, orientation, and preparation of the home. Please note: The Community Fee is non-refundable.*

I Understand and Agree
9. Independent Living Acknowledgment
Independent Living Acknowledgment

Our program is designed for individuals who are high-functioning and capable of living independently. We do not provide medical care, personal assistance, or supervision. You must manage the following independently:
- Hygiene
- Meals
- Medication
- Mobility
- Household tasks
- Emergency Evacuation
- Childcare
  If care is needed, it must be provided by a licensed outside provider
I understand agree to the Independent Living Acknowedgement*

Yes
10. Program Agreement Preview
I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins.*

Yes
I acknowledge that violating rules may result in a strike or dismissal from the program.*

Yes
11. Application Declaration

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.
Full Name*
Your application will be added to our waitlist for upcoming openings. We're always securing new homes and will contact you when a space becomes available.*

I Understand
Signature*

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KindWell Living Solutions Participant Intake & Enrollment Application

1. Date and Referral Information

2. Participant Information

3. Current Living Situation

4. Brief Summary of Situation

5. Medical & Mental Health History

6. Legal Background

7. Income Information

8. Housing Preferences

9. Independent Living Acknowledgment

10. Program Agreement Preview

11. Application Declaration