Supportive Housing Client Intake Form
ColScott Comfort Homes LLC
A place of comfort, dignity, and community.
Participant Intake & Enrollment Application
Date of Intake:
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Month
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Day
Year
Date
Referral Agency/ Name of Referrer:
Participant Information
Full Name:
*
Date of Birth:
*
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Month
-
Day
Year
Date
Age:
*
Social Security Number (Last 4 digits):
Phone Number:
*
Format: (000) 000-0000.
Email Address:
example@example.com
Gender:
Male
Female
Non-binary
Prefer not to say
Emergency Contact Name:
Relationship:
Emergency Contact Phone:
Format: (000) 000-0000.
Current Living Situation
Current Living Situation Options
Homeless
Couchsurfing / Staying with others
Transitional Housing
Jail/Prison Release
Hospital / Rehab
Other
Referral Source (If Applicable)
Referral Source Options
Self
Parole/Probation
Hospital or Treatment Center
Family/Friend
Other
Referring Contact Name:
Phone/Email:
Brief Summary of Situation / Reason for Housing Need
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Medical & Mental Health History (List Below)
Mental health diagnosis (if any):
*
Substance use history (if any):
Alcohol
Drugs
None
If yes, explain:
Legal Background
Are you currently on parole or probation?
*
Yes
No
Are you a registered sex offender?
*
Yes
No
(List PO Name/Phone Number)
Income Information
Do you have a source of income?
*
Yes
No
*
SSI
SSDI
Employment
Other
Monthly Income Amount (if any): $
*
Housing Preferences or Needs
Any disabilities or accommodations needed?
Yes
No
If yes, explain:
Preferred Room Type:
Shared Room
Private Room (if available)
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Independent Living & Functionality Acknowledgment
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)
Some Mobility and transportation arrangements
Some 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?
*
Yes
Other
Do you currently have or need a home health care provider or outside support service?
No
Other
*
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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Month
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Day
Year
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.
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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.
Participant Name:
*
Participant Signature:
*
Date:
*
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Month
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Day
Year
Date
Staff Name:
Signature:
Date:
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Month
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Day
Year
Date
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