Client Intake Form
Thank you for your interest in Unity Grace Living LLC. Please complete this form so we can determine eligibility and placement.
Note: For assistance completing this form call 252-777-3153
Nota: Para recibir ayuda para completar este formulario, llame al 252-777-3153.
Section 1 - Applicant Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Gender
*
Male
Female
Race/Ethnicity
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Current Living Situation/Address (if applicable)
*
Do you currently have identification? (select all that apply)
*
Identification card / Drivers License
Social Security Card
Birth Certificate
Passport / Visa
Green card
Do you identify as a member of the LGBTQ+ community?
*
Yes
No
Section 2 - Emergency Contact
Emergency Contact Name
Relationship to You
Emergency Contact Phone #
Section 3 - Background Information
Where are you transitioning from? (Select all that apply)
*
Homelessness / Unsheltered
Homeless Shelter
Hospital
Rehabilitation Facility
Transitional Housing
Foster Care / State Care
Correctional Facility / Re-entry
Behavioral health Facility
Living with Friends/Family
Other
Do you have a case manager, social worker, or program contact?
Yes
No
If yes, please provide name and contact information
Section 4 - Veteran Status
Are you a veteran?
*
Yes
No
If yes, branch of service:
Section 5 - Income & Benefits
Do you receive any of the following? (Check all that apply)
*
SSI
SSDI
VA Benefits
Employment Income
Unemployment
Food Stamps (SNAP)
Medicaid
Medicare
No Income
Other
Approximate monthly income amount (if any)
Section 6 - Health & Wellness
Do you have any disabilities?
*
Yes
No
If yes, please explain your disabilitie(s) or any accommodations needed:
Do you require assistance with any daily living activities?
*
Yes
No
If yes, please describe the type of assistance you need:
Do you have any medical conditions we should be aware of?
Do you take any prescribed medications?
*
Yes
No
If yes, please list medication:
Are you able to manage your own medications independently?
Yes
No
Section 7 - Behavioral Health & Substance Use
Have you ever been diagnosed with a mental health condition
*
Yes
No
If yes, please list (optional):
Do you currently use alcohol or substances?
*
Yes
No
Are you willing to maintain a substance-free living environment?
*
Yes
No
Section 8 - Legal Background
Note: This information is used to help ensure you have the resources needed. Answering "yes" to any question does not automatically disqualify you.
Do you currently have any pending criminal charges?
*
Yes
No
If yes, please explain: (include city and state of charge)
Are you currently on probation or parole?
*
Yes
No
Do you have any legal restrictions (curfew, registry, etc.)?
*
Yes
No
If yes, please explain:
Section 9 - Room & Fee Acknowledgement
Preferred Move-In Date
-
Month
-
Day
Year
Date
Preferred County
Please Select
Edgecombe
Nash
Pitt
Wayne
Wilson
Other
If preferred county is not listed, please list name of county below in Section 10.
I understand that Unity Grace Living LLC offers private and semi-private rooms and will provide an option to pay weekly, biweekly, or monthly. I also understand that my quoted rate includes a fully furnished home environment, electricity, water, washer & dryer, TV, Wi-fi, security, access to common living areas, and additional optional services.
*
I agree
Please be aware that a one-time $200 administrative fee is required to reserve your selected room. Your rent will be due on your move-in day and will be prorated if your move-in date is after the first of the month. Do you acknowledge and agree to these terms?
*
I agree
I understand that Unity Grace Living is a drug- and alcohol-free shared housing program and I agree to follow all house rules and guidelines to remain in good standing.
*
I agree
Section 10 - Additional Information
Is there anything else you would like us to know about your situation, needs, or preferred county?
If you are a case manager, social worker, discharge planner or other representative completing this form for the applicant, please complete the following fields:
Representative Name
Role/Title
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Section 11 - Consent & Signature
By submitting this form, I certify that the information provided is true and complete to the best of my knowledge. I understand that this form is for screening purposes and does not guarantee placement. Please allow 24 hours for processing. If urgent, please call the Administrative Director at 252-777-3153
*
I Agree
Signature
*
SUBMIT
SUBMIT
Should be Empty: