Housing Client Intake Form

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?*

YesNo - Please explain:
Do you currently have or need a home health care provider or outside support service?

Yes - Agency Name (if applicable):No
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.
Participant Initials:
Date:

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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.

STAR SAFE HAVEN
Participant Name:*
Participant Signature:*

Clear
Date:

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Staff Name:
Signature:

Clear
Date:

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Type a question
Should be Empty: