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
YESNO
If yes, how long have you been homeless?
VeteranSenior (65 and up)Adult needing affordable housingDomestic Violence SuvrvivorOther
Living Situation*
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.
YESNO
If yes, do you have medication, counselor, or supporting service in place for your mental health? Please explain.
YESNO
If you do have a physical disability, are you able to take care of yourself? What is your physical disability?
YESNO
YESNO
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
YESNO
SSISSDIEMPLOYEDPRIVATE PAYOTHER
Please describe OTHER type of income if it was selected.
What is your Monthly income?
YesNo
YesNoOther
How did you hear about our program?
Should be Empty: