Haven Housing Solutions Intake Form
Please complete this form to help us assess your housing needs and determine eligibility for our program.
This form may be completed by the applicant/client, a social worker, case manager, discharge planner, family/support person, or referral source. Please answer as accurately as possible so Haven Housing Solutions can determine whether our structured shared housing program is an appropriate fit.
Who is completing this form?
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Client/Applicant (self)
Social Worker/Case Manager
Family Member/ Support Person
Community Referral Partner/ Agency Representative
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Gender
*
Male
Female
Prefer not to say
Race/Ethnicity
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American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Prefer not to say
Current living situation?
*
Staying with family or friends
Currently in a shelter
Living in a hotel or motel
Currently homeless (no stable place to live)
Currently in another housing program
Being dischared from a hospital or treatment center
Transitioning from incarceration/Reentry
Domestic violence situation (seeking housing)
Other
What was your reason for leaving?
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Are you comfortable living in a shared housing environment with other adults?
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Yes
No
How soon is housing placement needed?
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Immediately (within 24-48 hrs)
Within 3-7 days
Within 1-2 weeks
Just exploring options
Do you currently have verifiable income and the ability to provide proof of income?
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Yes
No
What is your current monthly income source?
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SSI
SSDI
Employment / Wages
Retirement Income
Veteran Benefits
Family Support
No income at this time
Other
Approximate monthly income amount:
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Are there any mental health, emotional, or behavioral concerns Haven Housing Solutions should be aware of for safe shared housing placement? If yes, please explain. If no, type None.
*
Do you require hands-on assistance with bathing, dressing, toileting, eating, mobility/transfers, or personal hygiene?
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Yes
No
Are you able to live independently, manage personal needs, and follow house guidelines without hands-on assistance?
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Yes, I am totally independent and able to manage personal care, medications, and daily responsibilities on my own.
No, I need support with personal care, medication management, or daily responsibilities.
Are you able to self-administer medications independently? Haven Housing Solutions is not a medical facility and does not administer medications. Medication reminders may be available.
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Yes, I can manage my own medications
No, i will need some assistance with reminders
Are you disabled?
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Yes
No
List any disabilities:
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Do you require a handicapped accessible living environment?
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Yes
No
Have you ever been convicted of a crime? Please note that answering yes to this question does not automatically disqualify you.
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yes
no
If you answered yes, please explain:
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Are you a regsitered sex offender?
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Yes
No
Are you currently working with a social worker, case manager, parole officer, or any other program worker?
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yes
no
If yes, please provide their name and contact information
*
Are there any current or recent substance use, or is the applicant/client in recovery from drug or alcohol use?
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currently in recovery (no active use)
currently substance use
Prefer to discuss privatley
No current or recent substance use
Will any children be living with you in the home?
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Yes, children will be living with me
No, no children will be living with me
If yes, please provide their ages. This information helps us ensure the home environment is safe and appropriate for all residents.
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Select all services you will need during your stay.
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Transportation
Job Placement
Apply for SNAP benefits
Applying for Health Insurance
Donation (clothing/food)
Cellphone/Tablet Assistance
Therapy/Counseling
How did you hear about Haven Housing Solutions?
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Family or friend
Refferal from another organization or case worker
Social Media
Flyer, Brouchure, or business card
Community event or outreach program
Church
Shelter or housing agency
Probation,parole,or reentry program
Hospital or mental health provider
Word of mouth
Other
I understand that Haven Housing Solutions provides structured shared housing only. Haven Housing Solutions does not provide personal care, medical care, medication administration, hands-on daily living assistance, skilled nursing, or 24-hour supervision. The applicant/client must be able to live independently and manage personal needs or have outside supports in place.
*
Yes, I understand
No, I do not understand
Do you understand that this is a structured housing program and NOT a traditional lease?
*
Yes
No
By agreeing below, I certify that the information provided about the applicant/client is true and complete to the best of my knowledge. If completed by a referral source, I confirm this information is accurate to the best of my knowledge and applies to the applicant/client.
*
Yes, I certify all information provided is true and correct.
I am unable to verify all information provided.
Submit
Should be Empty: