Counseling Intake Form

Haven Housing Solutions Intake Form

Please complete this form to help us assess your housing needs and determine eligibility for our program.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemalePrefer not to say
Race/Ethnicity*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoWhitePrefer not to say
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Do we have permission to call/text the number provided?*

YesNo
Emergency contact name*
Emergency contact phone number*
Please enter a valid phone number.
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 facilityLiving in hotel or motelAt risk of losing their houseLocal 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 roomI prefer a shared roomI 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)RetirmentVoucherJobNo income
How often are you paid?*

WeeklyBi-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 medicationsI 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.*

yesno
Do you have any disabilities? If so, please specify. If not, please TYPE NONE*
Do you require a handicapped accessible living environment?*

YesNo
Have you ever been convicted of a crime? Please note that answering yes to this question does not automatically disqualify you.*

yesno
If you answered yes, please explain:
Are you a registred sex offender?*
Are you currently working with a social worker, case manager, parole officer, or any other program worker?*

yesno
If yes, please provide their name and contact information*
Are you in recovery from substance use (drug or alcohol)?

YesNo
Will any children be living with you in the home?*

Yes, children will be living with meNo, 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.*

TransportationJob PlacementApply for SNAP benefitsApplying for Health InsuranceDonation (clothing/food)Cellphone/Tablet AssistanceTherapy/Counseling
How did you hear about Haven Housing Solutions?*

Family or friendRefferal from another organization or case workerSocial MediaFlyer, Brouchure, or business cardCommunity event or outreach programChurchShelter or housing agencyProbation,parole,or reentry programHospital or mental health providerWord of mouthOther
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 understandNo, 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 regulationsNo
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Haven Housing Solutions Intake Form