supportivehousingclientintakeform3(1)

Supportive Housing Client Application

Open Door Solution

Participant Intake & Enrollment Application

Date of Intake

Date

Referral Agency Name of Referrer

Full Name

Date of Birth

Date

Phone Number:

Gender

Social Security Number Last 4 digits

Email Address

example@example.com

Emergency Contact Name

Relationship

Couchsurfing / Staying with others Transitional Housing Jail/Prison Release

Other

Referral Source (If Applicable)

Self

Agency

Hospital or Treatment Center Family/Friend Referring Contact Name: Phone/Email

Referring Contact Name

Brief Summary of Situation Reason for Housing Need

Medical & Mental Health History (List Below)Mental health diagnosis (if any):

Alcohol

Substance use history (if any): Alcohol Drugs None If yes, explain:

Are you currently on parole or probation? (List PO Name/Phone Number)

Are you a registered sex offender?

YesNo

Do you have a source of income?

SSISSDIEmploymentOther

Monthly Income Amount if any

Housing Preferences or Needs - Any disabilities or accommodations needed? Yes No - If yes, explain:

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:

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?

Yes

No Please explain

Do you currently have or need a home health care provider or outside support service? Yes - Agency Name (if applicable): No

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

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.

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

Staff Name

Signature

Date