BCG Intake Form

BCG Housing Client Intake Form
Date

MonthDayYear
Referral Agency / Name of Referrer:
Participant Information:
Name of applicant*

First NameLast Name
Date Of Birth*

MonthDayYear
Age*
Social Security Number (last 4 digits)*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Gender*
Emergency Contact Name

First NameLast Name
Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Cuurent Living Situation
Current Living Situation
Referral Source
Referral Source (if applicable):
Referring Contact Name / Phone / Email:
Brief Summary of Situation / Reason for Housing Need
Mental Health Questions Below
Medical & Mental Health History (list below)
Mental health diagnosis (if any):*
Please list any mental health diagnosis here:
Substance use history (if any):*
If answered "yes" to above question, please explain:
Legal Background
Are you currently on paraole or probation?*
If answered "yes" to above question, please list probation officer name & phone number:
Are you are registered sex offender?*
Income Information
Do you have a source of income?*
What type of source of income?*
f other income, please list monthly income amount (if any):
Housing Preferences or Needs
Any disabilities or accommodations needed?*
If answered yes to special needs / accomadaions (above queston), please explain:
Preferred room type*
IndependentLiving & Functionality Acknowledgment Heading
At BGC, our program is designed for individuals who are high-functioning and capable of living independently. This is not a personal care home, nursing home, or assisted living facility. We do not provide medical care, personal assistance, or supervision.

You must be able to manage your own:
- Personal hygiene and grooming
- Meal preparation and eating
- Medication (unless managed by an outside provider)
- Mobility and transportation arrangements
- Housekeeping and laundry
- Daily living responsibilities
If you require medical or personal care services, they must be provided by a licensed outside agency or caregiver, arranged and paid for separately.
Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?*
If no, please explain:
Do you currently have or need a home health care provider or outside support service?
If yes, please list agency name (if applicable):
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
Particpant Initials: Date:
Intitials: Date:
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.I acknowledge that violating rules will result in a strike or dismissal from the program.
Applicant 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.
Participant Name

First NameLast Name
Date

MonthDayYear
Date
Signature*

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Staff Name - Office Use Only

First NameLast Name
Staff Signature - Office Use Only

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Date Signed by staff - Office Use Only

MonthDayYear
Date
Should be Empty:

BCG Housing Client Intake Form

Participant Information:

Cuurent Living Situation

Referral Source

Mental Health Questions Below

Legal Background

Income Information

Housing Preferences or Needs

IndependentLiving & Functionality Acknowledgment Heading

Applicant Declaration