Intake Evaluation Form

Intake Evaluation Form

Please fill out the following form to register for the upcoming course designed for individuals interested in non-assisted independent shared living.
Full Name*

First NameLast Name
Gender*
Date of Brith*

MonthDayYear
Date
What is your race/ethnicity*

American Indian or Alaskan NativeAsianBlack or African AmericanHispanic Latino or LatineNative Hawaiian or Other Pacific IslanderWhite
Phone Number*
Please enter a valid phone number.
By checking this box, you consent to receive voicemails and phone messages at the number provided*
Email Address*
example@example.com
Residential Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is this form being filled out by a representative on behalf of another person?*
Representative's Organization*
Please briefly describe your clients current living situation.
What type of room does the client prefer?*

SharedPrivate
Will the client have any children living with them?*

YesNo
When does the client need to be placed?*

MonthDayYear
Date
How will the client pay for housing?*

SSI/SSSDIRetirementVoucherOrganization FundingJobOther
Do you receive Food Stamps/EBT (SNAP BENEFITS)?*

YesNo
How much income does client receive monthly? If none please type NONE*
Does the client require a handicap-accessible living environment?*

YesNo
Does client need help with daily activities (cleaning, cooking, hygiene, bathing etc.)?*

YesNo
Do you have any physical disabilities or mobility concerns?*

YesNo
If you have disabilities or mobility concerns, please explain.
Does the client currently take any prescribed medications?*

YesNo
Does the client suffer from mental illness?*

YesNo
Does the client need help recovering from opioids or any other drugs or alcohol?*

YesNo
Have you been convicted of a felony(Your answer to this question does not disqualify you from our program and services.)*

YesNo
Are you currently on probation or parole?*

YesNo
Is the client a sex-offender?*

YesNo
If yes, please explain include restriction/non restriction details.
Does the client smoke?*

YesNo
Does the client require service animal?*

YesNo
Does the client have pets?*

YesNo
Proof of Income*

Cancelof
Proof of Identification*

Cancelof
How did you hear about us?

ReferralSearch engine/webSocial Media
I agree to the terms and conditions related to the course registration.*

I agree
Digital Signature to Confirm Your Registration*

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