Housing Program- Pre- Screen Intake Application
Submission does not guarantee placement. Please answer all questions honestly.
Full Legal Name (Required)
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Current Living Situation
Primary Source of Income
If “Other,” please explain
Approximate Monthly Income (USD) (Required)
Health & Independent Living
Do you currently have any medical conditions that may impact independent living?
Yes
No
Are you able to are your medications independently?
Yes
No
Do you have any metal health diagnosis?
Yes
No
If “Yes” please explain
Do you require assistance with daily living activities?
Yes
No
If yes, please briefly explain
Applicant Full Name (Electronic Signature) (Required)
Signature
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Intake Assessment- Staff Only
Type a questionAssessment Completed By:
Assessment Date:
Does the applicant meet basic eligibility?
Yes
No
Communication Skills
Good
Fair
Concern
Hygiene
Good
Fair
Concern
Income Stability Verified
Yes
No
Behavioral or Safety Concerns
Decision
Additional Notes
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Continue
Should be Empty: