Intake Form for VA and Homeless

The Cynoya - Intake Complete Form - VA & Homeless

Please fill out this form completely for placement of client
Staff / Sponsor Name

First NameLast Name
Today's Date

MonthDayYear
Date
- Applicant's Legal Name
  
  First NameLast Name
- Preferred/Nick Name
- Gender
- Date of Birth
- SSN
- Most Recent Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Reason for Leaving Residence?
- Current Living Situation
  
  Other
- Do you understand the following? (Check all that apply)
- Previous Addresses (Last 2 years)
- Preferred Housing Location
- Room Type Request
- Move-in Date Requested
  
  MonthDayYear
  Date
- Sources of Income (check all that apply)
  
  Other
- Currently Employed?
- Total Monthly Income Amount
- If you are Currently Employed, fill out the Employment Information Section Below!
- Employer Name
- Employer Contact Info
- Income per Month
- Do you have proof of income?
- Primary Emergency Contact Name
  
  First NameLast Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Relationship
- Secondary Contact Name
  
  First NameLast Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Relationship
- Case Manager (if already assigned):
  
  First NameLast Name
- Agency Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Therapist (if applicable):
  
  First NameLast Name
- Probation Officer (if applicable)
  
  First NameLast Name
- Medical Conditionals (check all that apply)
- If Other, please specify
- Mental Conditionals (check all that apply)
- If Other, please specify
- Are you currently using any illegal substances?
- Are you willing to follow a drug‑free policy on the property?
- List of Current Medications (if any)
- Do you need assistance managing medications?
- TB Screening (Required)
  
  A tuberculosis (TB) screening is required to help protect the health and safety of all residents and staff living in a shared housing environment. Requiring a TB screening is a standard public health practice in congregate and transitional living settings and demonstrates a commitment to maintaining a safe, healthy living space for everyone in the home.
- Have you had a TB test within the last 12 months?
- If no, are you willing to complete a TB test?
- I understand that my health history plays a vital role in identifying eligibility in this program. I certify that the information on this Health Screening is accurate to the best of my knowledge. I also understand that If any of this information has been falsely stated, it is grounds for immediate termination from the program.
- Do you need assistance from a caseworker in obtaining any missing documents?
- Missing Documents (check all that apply)
  
  Other
- If Other, please specify
- Copy of Identification Front
  
  Cancelof
- I understand that participation in the program may require a background check for the safety of all residents.
- Copy of Identification Back
  
  Cancelof
- I acknowledge that The Cynoya Independent Living Housing offers shared housing with established house rules, expectations, and program guidelines designed to ensure a safe, respectful, and clean living environment for all residents. I agree to comply with all rules and to complete the intake process truthfully and in good faith.
- Signature
Should be Empty:

The Cynoya - Intake Complete Form - VA & Homeless