Haven Housing Solutions Intake Form
Please complete this form to help us assess your housing needs and determine eligibility for our program.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Prefer not to say
Race/Ethnicity
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Prefer not to say
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to call/text the number provided?
*
Yes
No
Emergency contact name
*
Emergency contact phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your current living situation?
*
Homeless ( staying outdoors,in a car, tent,or other place not meant for housing)
Temporarily staying with family or friends (couch surfacing)
Recently released from jail/prison or correctional facility
Living in hotel or motel
At risk of losing their house
Local Shelter
HHS offer both private and shared rooms. Please indicate your preference below. While we do our best to accommodate your choice, room assignment is based on availability.
*
I prefer a private room
I prefer a shared room
I am open to either private or shared room
How soon are you looking to move in?
*
Income Source (Select all that apply)
*
Social Security (SSI/SSDI)
Veterans Benefits (VA)
Retirment
Voucher
Job
No income
How often are you paid?
*
Weekly
Bi-weekly (every two weeks)
Semi-monthly (twice a month)
Monthly
Do you experience any mental health conditions or emotional challenges (such as depression,anxiety,PTSD,or bipolar disorder) if so, please explain. if not, TYPE NONE
*
Are you able to live independently, take care of your personal needs, and follow house guidelines without assistance?
*
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.
To help ensure your safety while living at Haven Housing Solutions, Please let us know if you take any prescription medications.
*
I currently take prescription medications
I do not take prescription medications
Do you self-administer? Please note, we are a not a medical facility and we cannot provide medical care or administer medications. However, we can do medication reminders.
*
yes
no
Do you have any disabilities? If so, please specify. If not, please TYPE NONE
*
Do you require a handicapped accessible living environment?
*
Yes
No
Have you ever been convicted of a crime? Please note that answering yes to this question does not automatically disqualify you.
*
yes
no
If you answered yes, please explain:
Are you a registred sex offender?
*
Please Select
Yes
No
Are you currently working with a social worker, case manager, parole officer, or any other program worker?
*
yes
no
If yes, please provide their name and contact information
*
Are you in recovery from substance use (drug or alcohol)?
*
Yes
No
Will any children be living with you in the home?
*
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 enviroment is safe and appropriate for all residents.
*
Select all services you will need during your stay.
*
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?
*
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 and agree that this program provides housing only. I am responsible for my personal care, medical needs, and daily living tasks. I acknowledge that Haven Housing Solutions is not responsible for providing any services outside of independent housing, and I agree not to hold the program liable for matters beyond housing support.
*
Yes, I understand
No, I do not understand
By agreeing below, I certify that the information provided is true and complete to the best of my knowledge. I understand that Haven Housing Solutions is a drug- and alcohol-free environment and that all residents must follow the program rules and policies to remain in good standing.
*
Yes, all information is true and i agree to abide by HHS rules and regulations
No
Submit
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