Gentle Hands Supported Living Intake Form
Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Current Address
Emergency Contact Name
Relationship
Phone
Format: (000) 000-0000.
Gender
Male
Female
Transgender
Other
Race
White
Black or African American
Hispanic or Lation
Asian
Native American
Other
Whats your primary language
What's your relationship status?
Single
Married
Married but sperated
Divorce
Other
Identification & Documentation
ID provided:
State ID
Drivers License
Other
ID Number
Expiration Date
/
Month
/
Day
Year
Date
Social Security Number
Are you currently on probation or parole?
Yes
No
If yes list supervising officer name and contact
Do you have any medical conditions we should be awareof?
Yes
No
If yes, explain:
Are you currently taking any medications?
Yes
No
If yes, explain:
Do you require special accommodations due to a disability?
No
Yes
If yes, explain:
Primary Care Provider Name
Phone
Format: (000) 000-0000.
Support & Behavorial Info
Are there any identified, past or current, domestic violence issues?
Yes
No
If yes, explain:
Is applicant a Veteran, (anyone who has been on active military duty)?
Yes
No
Child Welfare Involvement For Parents of minor children including noncustodial parents history of child welfare involvement including current case status
Have you previously lived in a shared housing or group home setting?
Yes
No
If yes, explain briefly:
Is this person at risk of homelessness?
Yes
No
If yes, please describe circumstances:
Length of homelessness this episode:
Not homeless at present
Less than one month
At least 1 month but less than 6 months
At least 6 months but less than 1 year
At least 1 year but less than 2 years
Two years but less than three
Three years or more
Within the last four 4 years how many nights months or years if any have you spent in a shelter s
Can you provide the names and dates of your shelter stay?
Where have you slept for the last thirty (30) days? Check all that apply.
Non-housing (Street, park, car)
Emergency shelter please name
Transitional Housing
Psychiatric Facility
Substance Abuse Treatment Facility
Hospital
Prison/Jail
Domestic Violence Shelter
Living w/ friends/family
Rental Housing
Own apartment or house
Motel/hotel
Foster Care
Other
Is applicant receiving a housing subsidy?
Yes
No
What type of housing subsidy is the applicant receiving
Does/did applicant pay own rent?
Yes
No
Does/did applicant pay for own utilities?
Yes
No
Reason for leaving last housing situation.
Eviction due to unpaid rent
Eviction for reason other than unpaid rent
Conflict with friends or family
Overcrowding
Domestic violence
Incarceration
Hospitalization, including long term treatment
Housing condemned
Fire
Other
Does applicant have a disability of a long duration?
Yes
No
I dont know
Do you have a history of any of the following: Substance use if yes, what/ frequency/ last date of use?
Substance abuse
Mental health treatment
Behavioral issues in shared housing
Mental illness if yes, what
Alcohol abuse if yes, what/ frequency/ last date of use?
Drug overdose if yes, when and what?
HIV/AIDS and related diseases
Developmental disability
Physical disability
None
Substance use if yes, what/ frequency/ last date of use?
Mental illness if yes, what
Alcohol abuse if yes, what/ frequency/ last date of use?
Drug overdose if yes, when and what?
Check all that apply:
Homicidal ideas/attempts
Assaultive behavior
Delusions
Severe depression
Severe thought disorder
Cognitive impairment
Suicidal ideas
Suicidal attempts
Hallucinations
Arson/fire setting
Victim of sexual abuse/assault
Victim of trauma
Other
Does applicant have any current or past history of substance abuse treatment?
Yes
No
Is applicant involved in any 12-step or other self-help recovery programs?
Yes
No
If yes, where/when?
Does applicant have a history of any psychiatric conditions
Yes
No
If yes please list hospitalizations for these conditions
Does applicant receive psychiatric care?
Yes
No
If yes, please list name, address and phone number of all psychiatric care providers.
Do you have a caseworker or social service contact?
Yes
No
Name
Number
If no, would you like one?
Yes
No
Does applicant have a history of any medical conditions?
Yes
No
If yes, please name them:
Please list hospitalizations for these medical conditions.
Date of last physical; OB/GYN, and dental appointments:
Is applicant allergic to any medications If yes, what and reaction?
Please list current medication list:
Where is the pharmacy and phone number?
Describe applicant participate in any social networks, or recreational activities? Please list the name(s) of the social/recreational network:
What is the applicant's main source of income?
Does applicant or anyone living with him/her have any entitlements pending?
Yes
No
What entitlement(s) is/are pending? Source of Income (type letter you chose in box) a. Social Security Income (SSI) b. Social Security Disability Income (SSDI) c. General Assistance (SAGA) d. Temporary Aid to Needy Families (TANF) e. Child Support f. Alimony g. Veteran Benefits h. Employment Income i. Unemployment j. Medicare k. Medicaid l. Food Stamps m. Other (please specify) n. No financial resources Input letter in box below
Include the following: Date Applied & Amount Receiving
Please list any outstanding debts, including type of debt and amount?
Please list any financial obligations including the amount (e.g. child support, alimony)?
Is applicant currently employed, either part-time or full-time?
Part time
Full time
Not employed
Self employed
Is applicant currently participating in vocational or employment training programs?
Yes
No
If yes, please identify the training program:
Does applicant have any current legal issues?
Yes
No
If yes, please list description of charges and any pending court dates.
Does applicant have legal representation?
Yes
No
If yes, please list name and address and phone number of attorney or legal advocate.
Is applicant currently on probation?
Yes
No
Is applicant currently on parole?
Yes
No
If yes to either two previous above questions, please list name and contact information of probation/parole officers(s)
Does applicant have any prior arrests, convictions or incarceration? ☐ Yes ☐ No If yes, please list.
Yes
No
If yes, please list.
Does applicant have a conservator?
Yes
No
If yes, please list
Does the applicant have difficulty with any of the following areas of daily living? In addition, please list any strengths the tenant may have. Check all that apply.
Paying Rent/ Utilities
Lease Compliance
Housekeeping
Money Arrangement
Driving / Using public transportation
Arranging apartment repairs
Use of mental health services
Use of health services
Securing / Maintaining Benefits
Meal Preparation
Shopping for food and other necessities
Filling Prescription
Socialization
Hygiene
Other
Emergency Contact Name/ relationship & Number
Preferred Move-In Date:
-
Month
-
Day
Year
Date
Do you require assistance with:
Transportation
Medication reminders
Daily routines
None
Are you comfortable sharing common spaces with other adults?
Yes
No
Do you have any allergies (food/environmental)?
Yes
No
List:
Source(s) of Income:
SSI/SSDI
Employment
Family Support
Other
Monthly Income Estimate:
Are you able to pay the community fee and renton time?
Yes
No
Would you like help applying for rental assistance if available?
Yes
No
I certify that the above information is true and accurate to the best of my knowledge.
I understand this form does not guarantee acceptanceinto housing.
Signature
Date
-
Month
-
Day
Year
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