Form
The Bradshaw House Intake Form
Applicant Information
Full Name
*
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Non-binary
Prefer not to say
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Current Address
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
*
Submit
Housing Situation
Current Housing Status
*
Staying with friends/family
Temporary shelter
Hotel/Motel
No stable place to stay
Other
Length Without Stable Housing
*
Less than 1 month
1–3 months
3–6 months
6–12 months
1+ year
Reason for Transitional Housing
Domestic violence
Eviction
Financial hardship
Mental health challenges
Substance use recovery
Returning citizen (post-incarceration)
Youth aging out of foster care
Other
Background Information
Are you a Veteran?
*
Yes
No
Benefits Received
SSI/SSDI
SNAP
Medicaid
None
Medical Conditions or Disabilities
Employment & Income
Employment Status
*
Full-time
Part-time
Unemployed
Self-employed
Student
Unable to work
Monthly Income
*
No income
Under $500
$500–$1,000
$1,000–$2,000
$2,000+
Substance Use & Recovery
Are you currently in recovery?
*
Yes
No
Do you want recovery support?
*
Yes
No
Support Services Needed
Check all that apply
Case management
Employment assistance
Mental health support
Financial literacy
Food assistance
Transportation assistance
Clothing/hygiene resources
Life skills coaching
Legal Information
Are you on probation or parole?
*
Yes
No
Legal matters you want us to be aware of
Household Information
Dependents staying with you?
*
Yes (add names/ages)
No
Personal Goals
What are your top 3 goals for the next 6 months?
What support do you need to reach these goals?
Program Requirements Agreement
Program Requirements Agreement
*
I understand this is transitional housing, not permanent housing.
I agree to follow all house rules and guidelines.
I agree to attend case management meetings.
I agree to treat staff and residents respectfully.
Signatures
Applicant Signature
*
Date
*
-
Month
-
Day
Year
Date
Staff Signature (Office Use Only)
Date
-
Month
-
Day
Year
Date
Identification
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