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  • Supportive Housing Client Intake Form

  • Star Safe Haven

  • Participant Intake & Enrollment Application
  • Date of Intake:
     - -

  • Participant Information

  • Date of Birth:*
     - -
  • Format: (000) 000-0000.
  • Gender:*
  • Format: (000) 000-0000.

  • Current Living Situation

  • Current Living Situation*

  • Referral Source (If Applicable)

  • Referral Source
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  • Medical & Mental Health History (List Below)

  • Mental health diagnosis (if any):

  • Substance use history (if any):*

  • Legal Background

  • Are you currently on parole or probation? (List PO Name/Phone Number)*
  • Are you a registered sex offender?*

  • Income Information

  • Do you have a source of income?*
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  • Housing Preferences or Needs

  • Any disabilities or accommodations needed?*
  • Preferred Room Type:*

  • Independent Living & Functionality Acknowledgment

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  • STAR SAFE HAVEN

    Our program is designed for individuals who are high-functioning and capable of living independently. This is not a personal care home, nursing home, or assisted living facility. We do not provide medical care, personal assistance, or supervision.

    You must be able to manage your own:

    • Personal hygiene and grooming
    • Meal preparation and eating
    • Medication (unless managed by an outside provider)
    • Mobility and transportation arrangements
    • Housekeeping and laundry
    • Daily living responsibilities

    If you require medical or personal care services, they must be provided by a licensed outside agency or caregiver, arranged and paid for separately.

  • Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?*
  • Do you currently have or need a home health care provider or outside support service?
  • I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing.
  • Date:
     - -

  • Program Agreement Preview

  • I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins.
    I acknowledge that violating rules may result in a strike or dismissal from the program.

  • Applicant Declaration

  • I certify that the above information is true to the best of my knowledge. I understand that this intake does not guarantee placement, and my application will be reviewed by staff.
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  • STAR SAFE HAVEN
  • Date:
     - -
  • Date:
     - -
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  • Should be Empty: