Day Rise Living — Intake Assessment

Day Rise Living — Intake Assessment
Welcome to Day Rise Living

This intake assessment is for individuals interested in joining the Day Rise Living transitional housing program, which provides safe, supportive, and respectful housing for adults seeking stability and a fresh start. The information collected will help us determine eligibility and ensure our program is a good fit for your needs.

Please answer all questions honestly and completely. Submission of this assessment does not guarantee acceptance into the program. All information will be kept confidential and used solely for program evaluation and placement purposes.
Section 1: Participant Information
Full Name*
Date of Birth*

MonthDayYear
Date
Last 4 digits of Social Security Number (optional)
“This information is collected solely for identity verification and will remain confidential under HIPAA and state privacy standards.”
Phone Number*
May we contact you by phone or text regarding housing availability and updates?*

Yes, you may call meYes, you may text meNo, I prefer email onlyOther
Email Address
example@example.com
Emergency Contact (Name / Relationship / Phone)
Your consent allows Day Rise Living to send limited updates related to housing and support services. You may opt out anytime.
Section 2: Living Situation & Room Preference
What is your current living situation?*

HomelessStaying with family or friendsTransitional programOther (please explain)
What type of room are you seeking?*

Shared Room (semi-private)Private Room
Desired move-in date:

MonthDayYear
Date
Section 3: Health & Wellness
All information is confidential and used only to determine appropriate housing support.
Do you currently have a mental health diagnosis?*

YesNoPrefer not to sayIf yes, please specify (optional)
Are you under the care of a doctor, psychiatrist, or therapist?*

YesNo
Are you prescribed any medications?*

YesNo
If yes, are you independent in managing your medication?*

YesNo, I need assistance
Do you require help with Activities of Daily Living (ADLs) such as bathing, dressing, meal prep, or transportation?*

IndependentNeed Some AssistanceNeed Full Assistance
Do you have any medical conditions or allergies we should be aware of?*
Do you use any medical or sleep-related devices at night (e.g., CPAP, oxygen, etc.) that we should be aware of for placement purposes?*

YesNoIf yes, please explain (optional):
Section 4: Income & Benefits
Do you have a verifiable source of income?*

YesNo
If yes, please indicate:*

EmploymentSSISSDIVA BenefitsOther (specify):
Section 5: Legal Background
A criminal background does not disqualify you. This information helps us meet compliance and safety guidelines.
Have you ever been convicted of a crime?*

YesNoIf yes, please explain (optional):
Are you a registered sex offender?*

YesNo
Section 6: Substance Use
Are you currently using or recovering from substance use (alcohol or drugs)?*

NoIn RecoveryCurrently UsingPrefer not to sayIf in recovery, how long have you been sober?
Section 7: Lifestyle & Room Compatibility
Do you smoke cigarettes or vape?*

YesNoOccasionally
Are you comfortable sharing a room with another participant (if applicable)?*

YesNoPrefer Private Room
Section 8: Support System / Circle of Support
Do you currently have a support system (caregiver, case manager, family, or friend)?*

YesNoIf yes, please list names, relationship and contact information (optional):
Are you receiving services from any agency or program (e.g., Regional Center, VA, Behavioral Health, Reentry Program)?*

YesNoIf yes, please specify:
Section 9: Identification Upload
Used only to verify identity. All files are securely stored and kept confidential.
Please upload a valid Photo ID (Driver's License, State ID, Passport, or Veteran ID):*

Upload ID
Upload only image or PDF file (.jpg, .png, .pdf)

Cancelof
Section 10: Additional Information
Gender Identity / Pronouns: (optional)*
Veteran Status:*

YesNoActive ServiceRetired
Transportation Access:*

Public TransitPersonal VehicleNeeds Assistance
Preferred City or Area:*
Anything else you'd like us to know to help determine the best placement for you:*
Section 11: Consent & Signature
I certify that the information provided above is true and complete to the best of my knowledge. I understand that providing false information may affect my eligibility for placement. All information will remain confidential within Day Rise Living and its affiliated programs.
Signature*

Clear
Date*

MonthDayYear
Privacy & Confidentiality Notice

Day Rise Living respects and protects your privacy. All personal and health information shared in this form is strictly confidential and used only to determine appropriate housing placement and support services.

Information is stored securely and will not be shared with outside parties without your written consent, except as required by law or authorized agencies directly involved in your care or placement.
Should be Empty:

Day Rise Living — Intake Assessment

Section 1: Participant Information

Section 2: Living Situation & Room Preference

Section 3: Health & Wellness

Section 4: Income & Benefits

Section 5: Legal Background

Section 6: Substance Use

Section 7: Lifestyle & Room Compatibility

Section 8: Support System / Circle of Support

Section 9: Identification Upload

Section 10: Additional Information

Section 11: Consent & Signature