Humanity Solutions Client Intake Form

Humanity Solutions Client Intake Form

Welcome to Humanity Solutions. We are a structured shared housing program. Please fill out this form to help us understand your needs and preferences for independent living. We do not provide medical care. All applicants must be functionally independent.
Full Name

First NameMiddleLast Name
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Email Address
Are you homeless?
If yes, how long have you been homeless?
Which best describes you?
Living Situation
Have you ever been convicted of any felonies? This will NOT disqualify from the program.
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?
If yes, do you have medication, counselor, or supporting service in place for your mental health? Please explain.
Do you have any physical disabilities?
If you do have a physical disability, are you able to take care of yourself? What is your physical disability?
Do you use drugs or alcohol?
Do you have a history of drug or alcohol abuse?
If yes, how long have you been sober?
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?
What is your income source?
Please describe OTHER type of income if it was selected.
What is your Monthly income?
Do you have any mental health diagnoses
Are you currently taking any medications?

Other
How did you hear about our program?
Should be Empty: