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.
Full Legal Name*

First NameMiddle NameLast Name
Social Security Number *
Gender*
Race*
Date of Birth (MM/DD/YYYY)*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Permission to Call/Text?*

YesNo
Best Time to Reach You*
Emergency Contact

Who can we contact in an emergency?
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Relationship to You*
Housing History

Tell us about your current living situation.
Which best describes you? (Select all that apply)*

HomelessCouch surfingLiving in shelterTransitional housingRecently incarceratedStaying with family/friendsDomestic violence survivorSubstance use recoveryMental health stabilizationOther
How long have you been in this situation?*
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Current Living Situation*
Reason for Seeking Housing*
Have you ever been evicted?*

YesNo
If yes, please explain*
Have you lived in shared housing before?*

YesNo
If yes, please explain*
Background & Legal History

Tell us about your legal background.
Are you currently on parole or probation?*

YesNo
If yes, please explain*
Any pending legal matters or court dates?*

YesNo
If yes, please explain*
Registered Sex Offender?*

YesNo
If yes, please explain*
Felony convictions in the past 10 years?*

YesNo
If yes, please explain*
History of violent crime?*

YesNo
If yes, please explain*
Any active restraining or protective orders?*

YesNo
If yes, please explain*
Health & Support

Tell us about your health and support needs.
Do you receive support services (caseworker, counseling, MAT, SUD, disability services)?*

YesNo
If yes, please explain*
Do you have any disabilities or special needs?*

YesNo
If yes, please explain*
History of substance use?*

YesNo
If yes, please explain*
Medical conditions requiring ongoing care?*

YesNo
If yes, please explain*
Prescribed medications?*

YesNo
If yes, please explain*
Injectable medications?*

YesNo
If yes, please explain*
Mental health conditions?*

YesNo
If yes, please explain*
Mobility or accessibility needs?*

YesNo
If yes, please explain*
Employment & Income

Tell us about your employment and income.
Employment Status*

Full-timePart-timeUnemployedTemp/ContractSSI/SSDIOther
Current Income Source(s)*

EmploymentSSISSDIUnemploymentVA BenefitsNoneOther
Monthly Income (Estimate)*
Proof of Income Available?*

YesNo
If yes, please explain*
Do you have a representative payee?*

YesNo
If yes, please explain*
Housing Readiness & Preferences

Tell us about your housing needs.
Date you need placement*

MonthDayYear
Date
Desired length of stay*
Room preference*

SharedPrivateNo Preference
Concerns about living with others?*

YesNo
If yes, please explain*
Do you have personal belongings or furniture?*

YesNo
If yes, please explain*
Transportation needs*
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)*

Employment or job stabilityMental health stabilizationSubstance recovery supportLife skills developmentFinancial literacy or budgetingAccessing community resourcesImproving daily structure and accountabilityReentry supportEducation or training goalsOther
Describe your top 3 goals*
Program Agreement & Understanding

Please read and acknowledge the following.
Open to scheduled room inspections?*

YesNo
If no, please explain*
Willing to follow AnchorPath Living House Rules?*

YesNo
If no, please explain*
Able to live independently without personal care assistance?*

YesNo
If no, please explain*
Understand this is NOT assisted living?*

YesNo
Agree to a drug- and alcohol-free environment?*

YesNo
Agree to month-to-month housing terms?*

YesNo
Agree to pay program fee on time?*

YesNo
Understand violations may result in termination?*

YesNo
All information provided truthful?*

YesNo
If no, please explain*
Referral Information

How did you hear about us?
How did you hear about AnchorPath Living?*
Referring Agency (if any)*
Signature

Please sign and date below.
Typed Signature*
Today's Date*

MonthDayYear
Date
Should be Empty:

AnchorPath Living – Housing Intake Form

Personal Information

Emergency Contact

Housing History

Background & Legal History

Health & Support

Employment & Income

Housing Readiness & Preferences

Personal Goals

Program Agreement & Understanding

Referral Information

Signature