Humanity Solutions Client Intake Form

Humanity Solutions Client Intake Form

Please fill out this form to help us understand your needs and preferences for independent living.
Full Name

First NameMiddleLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Are you homeless?

YESNO
If yes, how long have you been homeless?
Living Situation*
Gender*
Have you ever been convicted of any felonies?*

YESNO
If you have been convicted of felonies,please explain. This does not disqualify you from our program.
Are you on house arrest or probation? If yes, how long. This does not disqualify you from the program.
Do you have any pending charges? If yes, please explain.
Have you ever been diagnosed with any mental health conditions?

YESNO
If yes, do you have medication, concealer, or supporting service in place for your mental health? Please explain.
Do you have any physical disabilities?

YESNO
If you do have a physical disability, are you able to take care of yourself? What is your physical disability?
Do you have a history of drug or alcohol abuse?

YESNO
If yes, how long have you been sober?
Do you use drugs or alcohol?

YESNO
Drugs and Alcohol are not permitted in Humanity Solutions homes. This is a sober living environment.
What is your desired move in date?

MonthDayYear
Date
Do you have consistent income?

YESNO
What is your form of income?

SSISSDIEMPLOYEDOTHER
Please descibe other type of income if it was selected.
What is your Monthly income?
How did you hear about our program?
Should be Empty: