2nd Season Community Services Intake Form

2nd Season Community Services Intake Form

Complete this form to be added to our Waiting List!
Client Information
Client Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex at Birth*

MaleFemale
Race*

AsianBlack/ African AmericanCaucasianHispanicOther
Preferred Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail Address
example@example.com
Do you have children that are joining the program with you? (If yes, how many?)*
Emergency Contact Full Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship to Client:
Representative Name (if applicable)

First NameLast Name
Representative Organization (if applicable)
Current Living Situation
Select all that apply*

HomelessTransitional HousingJail/ Prison ReleaseHospital/ Rehab DischargeSenior
Brief Summary of Reason for Housing Need:*
Referral Source (if applicable)

SelfAgencyParole/ ProbationHospital or Treatment CenterFamily/ Friend
Do you have a valid ID/Driver’s License?*
If no, we will assist with obtaining one.
Do you have a copy of your birth certificate?*
If no, we will assist with obtaining one.
Do you have a copy of your birth social security card?*
If no, we will assist with obtaining one.
Medical History
Please list any medical history including allergies:
Please list any medication(s) you currently take:
Do you have any mental health diagnosis?*
Do you have any mental health diagnosis that are untreated?*
Are you recovering from drug or alcohol addiction?*
Substance use history (if any)
Legal Background
Do you have a criminal record?*
This does not disqualify you from the program.
Are you currently on probation or parole?*
This does not disqualify you from the program.
Are you a registered sex offender?*
This does not disqualify you from the program.
Income Information
Do you have a source of income?*
What is your source of income?*
Monthly income amount (if any):*
(Type "0" if none)
Housing Preferences
Are you comfortable living in a shared environment?*
Preferred room type*
Do you require short-term or long-term housing?*

Long-termShort-termUnknown
Do you require first-floor housing or have restrictions with stairs?*
Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?*
Do you currently have or need a home health care provider or outside support service?*
Will you require any wheelchair-accessible features, mobility assistance, or other accommodations?*
Independent Living & Functionality Acknowledgment

Our program is designed for individuals who are 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 24/7 in person supervision. You must be able to manage your own: Personal hygiene and grooming ; 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.
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.*

Yes, I understand.No, I do not understand.
If selected for the program do you consent to fully comply with all program policies and house rules at all times?*

Yes, I understand.No, I do not understand.
Select all of the services you are requesting:

Job Placement AssistanceApply for SNAP benefitsApply for SSI/SSDIOrganizational PayeeHealth Insurance EnrollmentClothing DonationsCell Phone/ Tablet AssistanceLife Skills
Desired move in date*

MonthDayYear
Date
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.*

First NameLast Name
Should be Empty:

2nd Season Community Services Intake Form

Client Information

Current Living Situation

Medical History

Legal Background

Income Information

Housing Preferences

Independent Living & Functionality Acknowledgment