Form

Form
Supportive Housing Client Intake Form
Date of Intake:
Referral Agency/Name of Referral:
Participant Information:
Name

First NameLast Name
Age:
Social Security Number (Last 4 Digits):
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
MaleFemaleNon-binaryPrefer not to say
Emergency Contact Name:
Relationship:
HomelessCouchsurfing /Staying with othersTransitional HousingJail/Prison ReleaseHospital/RehabOther
SelfAgencyParole/ProbationHospital/RehabFamily/Friend
Referral Contacting Name:
Phone/Email:
Agency Name:
Brief Summary of Situation/ Reason for Housing Need
Medical & Mental diagnosis (If any):
If yes, explain:
AlcoholDrugsNone
Legal Background
YesNo
Income Information
YesNo
SSISSDIEmploymentOther
Monthly Income Amount (If any):
Housing Preferences or needs
YesNo
If yes, explain:
Shared RoomPrivate Room (if available)
Independent Living & Functionality Acknowledgement
Our program is designed for individuals who are highly functioning and capable of living independently. This is not a personal care home, nursing home, nor assisted living facility. We do not provide medical care, personal assistance or supervision.

You must be able to manage your own:

·      Personal hygiene and grooming

·      Meal preparation and eating

·      Mobility and transportation

·      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.
YesNo
If no, explain:
YesNo
If no, explain:
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.
Applicant Declaration
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:

First NameLast Name
Participant Signature:

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Staff Name:

First NameLast Name
Signature:

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Date:

MonthDayYear
Date
Should be Empty:

Form

Supportive Housing Client Intake Form

Participant Information:

Medical & Mental diagnosis (If any):

Legal Background

Income Information

Housing Preferences or needs

Independent Living & Functionality Acknowledgement

Applicant Declaration