New Beginnings Supportive Homes Intake Form

New Beginnings Supportive Housing Intake Form

Please complete the form below with your most up-to-date information to proceed to the next step.
Applicant's Personal Information
Applicant Full Name*
Applicant Phone Number*
Format: (000) 000-0000.
Applicant Email*
example@example.com
Application Date*

MonthDayYear
Date
Who referred you? How did you hear about us? Kindly put name of person/agency.*
Who Is The Application for?

MyselfFamily MemberA client (I am a - Case worker/referral agency/social worker/sponsor)
Age*
Gender*

MaleFemaleOther
Preferred Move In Date?*

MonthDayYear
Date
What is your budget?*
Which type of room would you prefer?

Private RoomShared RoomAny
Are you aware that this is a shared living home?*

YesNo
Have you lived in shared housing before?*

YesNo
Are you coming from another group home?*

YesNo
If yes please specify which one and for how long you've been living there and the reason for leaving.
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long would you like to be a resident of our home?*

1-3 months4-6 months6-12 months1-2 years
Any criminal history?*

YesNo
If yes, please provide details of any criminal charges or convictions you have. Including the nature of the charges and any associated legal outcomes.
Do you have a probation officer? If so what is their name, phone number and extension?
Funding Source Details
Funding Source (Check all that apply)*

Self PayVoucherSocial Security InsuranceSocial Security Disability InsuranceGovernment or State OrganizationNon Profit Organization - Rent AssistanceOther
If you've received a voucher, what is the voucher's name? Write "N/A" if this doesn't apply.
Are you employed?*

YesNo
If you are employed, what are your hours/shift and what city do you work in? (If not applicable, please put N/A)
If you are employed, name & address of employer? (If not applicable, please put N/A)
What is the monthly income that you receive?*
What is the specific date that your payment is disbursed?
Any additional Income Information e.g., Part-time job?
If you are not employed, do you intend to apply for a job within 1 month of your arrival in New Beginnings Supportive Housing?

YesNo
If you don't intend on working or going to school, etc., explain why not and what you plan on doing with your daytime hours?
Health Details
Are you pregnant?*

YesNo
Please disclose any existing medical/mental conditions or health concerns that we should be aware of. What have you been diagnosed with, if any?*
Do you have any food or drug allergies? If yes, please elaborate.*
Are you currently taking any medications?*

Yes - Prescription medicationYes - Over the counter medicationNo
Are you currently taking any medications as part of your recovery treatment?*

YesNo
If yes, please specify which one/s.
Are you involved in any other support groups or programs related to recovery? *
How long have you been in recovery? Please provide details about your recovery journey. (If this doesn't apply write N/A)
Have you completed any rehabilitation or treatment programs? If yes, please provide details. (If this doesn't apply, write N/A)*
Do you have a history of relapse? If yes, please provide details and specify if you have a relapse prevention plan in place. (If this doesn't apply, write N/A)*
Do you have a sponsor or are you/will you be actively seeking one? (Please specify) (If this doesn't apply, write N/A)*
Do you have any specific needs or requirements related to your recovery journey that you would like us to be aware of?*
Primary Mode of Transportation?*

Public TransportationPersonal Vehicle
Do you smoke?*

YesNo
If yes, what do you smoke?
Any important details we should be aware of not yet addressed?
We have house rules to govern the safety and harmony of the home. Would you abide by them?*

YesNo
Consent to Verification of Other Information
I warrant, to the best of my knowledge, all of the information provided in this Application is true, accurate, complete and correct as of the date of this Application. If any information provided by me is determined to be false, such false statement will be grounds for disapproval of my Application or termination of my Agreement with Owner. I understand and agree:

(i) this is an application to rent only and does not guarantee that I will be offered the Property, and

(ii) Lessor may accept more than one application for the Property and, using their sole discretion, will select the best qualified applicant.

I hereby authorize the Lessor to verify the information provided.
Signature
Should be Empty:

New Beginnings Supportive Housing Intake Form

Applicant's Personal Information

Funding Source Details

Health Details

Consent to Verification of Other Information