AnchorPath Living – Housing Intake Form

  • AnchorPath Living – Housing Intake Form

    Apply for independent housing with AnchorPath Living in the NC Triad. All submissions are confidential.

  • Personal Information

    Tell us about yourself.
  • Date of Birth (MM/DD/YYYY)*
     - -
  • Format: (000) 000-0000.
  • Permission to Call/Text?*

  • Emergency Contact

    Who can we contact in an emergency?
  • Format: (000) 000-0000.

  • Housing History

    Tell us about your current living situation.
  • Which best describes you? (Select all that apply)*
  • Have you ever been evicted?*
  • Have you lived in shared housing before?*

  • Background & Legal History

    Tell us about your legal background.
  • Are you currently on parole or probation?*
  • Any pending legal matters or court dates?*
  • Registered Sex Offender?*
  • Felony convictions in the past 10 years?*
  • History of violent crime?*
  • Any active restraining or protective orders?*

  • Health & Support

    Tell us about your health and support needs.
  • Do you receive support services (caseworker, counseling, MAT, SUD, disability services)?*
  • Do you have any disabilities or special needs?*
  • History of substance use?*
  • Medical conditions requiring ongoing care?*
  • Prescribed medications?*
  • Injectable medications?*
  • Mental health conditions?*
  • Mobility or accessibility needs?*

  • Employment & Income

    Tell us about your employment and income.
  • Employment Status*
  • Current Income Source(s)*
  • Proof of Income Available?*
  • Do you have a representative payee?*

  • Housing Readiness & Preferences

    Tell us about your housing needs.
  • Date you need placement*
     - -
  • Room preference*
  • Concerns about living with others?*
  • Do you have personal belongings or furniture?*

  • Personal Goals

    What are your goals while living with AnchorPath Living?
  • What personal goals would you like AnchorPath Living to help you work toward? (Select all that apply)*

  • Program Agreement & Understanding

    Please read and acknowledge the following.
  • Open to scheduled room inspections?*
  • Willing to follow AnchorPath Living House Rules?*
  • Able to live independently without personal care assistance?*
  • Understand this is NOT assisted living?*
  • Agree to a drug- and alcohol-free environment?*
  • Agree to month-to-month housing terms?*
  • Agree to pay program fee on time?*
  • Understand violations may result in termination?*
  • All information provided truthful?*

  • Referral Information

    How did you hear about us?

  • Signature

    Please sign and date below.
  • Today's Date*
     - -
  • Should be Empty: