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.Format: (000) 000-0000.
Email:
example@example.com
Gender
Emergency Contact Name:
Relationship:
Current Living Situation

Other
Referral Source (If Applicable)
Referral Contacting Name:
Phone/Email:
Agency Name:
Brief Summary of Situation/ Reason for Housing Need
Medical & Mental diagnosis (If any):
If yes, explain:
Substance use history (If any):
Legal Background
Are you currently on Parole or Probation? (List PO Name/Phone Number)
Income Information
Do you have a source of income?
Other
Monthly Income Amount (If any):
Housing Preferences or needs
Any disabilities or accommodations needed?
If yes, explain:
Preferred Room Type:
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.
Can you live Independently and manage your Activities of Daily Living (ADL) without assistance?
If no, explain:
Do you currently have or need a home health care provider or outside support assistance?
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:
Program Agreement Preview
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:
Staff Name:

First NameLast Name
Signature:
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