Intake Assessment Form

Intake Assessment Form

Please complete this form to help us assess your application for housing and services with Resilient Roots Living.
Applicant Information

Please provide your basic contact and referral details.
Full Legal Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Application

MonthDayYear
Date
Referral Source

Other
Personal Information

Tell us about yourself.
Age
Gender

Other
If you are female, are you pregnant?
If yes, expected due date

MonthDayYear
Date
Veteran Status
Do you identify as having a disability? (Disclosure is voluntary and used only for reasonable accommodation purposes.)
Marital Status
Can you speak fluent English?
Housing History

Provide your recent housing background.
Current or Previous Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Length of Stay at This Address
If no address applies, what was your living situation immediately prior to this application?

Other
Reason for leaving your previous/current housing
Legal Information

Legal status and history.
Currently on Probation?
Currently on Parole?
Parole / Probation Officer Name
Officer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Any Pending Legal Cases?
If yes, upcoming court dates
Income Information

Please indicate your sources of income.
Source of Income (check all that apply)

Other (specify)
Employment & Education

Tell us about your employment and education background.
Highest Level of Education Completed
Do you own a vehicle?
Employment Status

Other (specify)
If employed, please provide the following:

Complete the following only if you are currently employed.
Company Name
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Position/Title
Supervisor/Manager Name
Days & Hours of Work
Program Interest & Goals

Help us understand your goals and expectations.
Why are you seeking housing with Resilient Roots Living?
What personal, housing, or independent living goals would you like to achieve while residing here?
Acknowledgement & Signature

Please read and sign below to acknowledge your understanding.
I understand that: Housing at Resilient Roots Living is not a licensed facility. Participation in services is voluntary. Housing and services are not contingent upon one another. I certify that the information provided is accurate to the best of my knowledge.
Applicant Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Intake Assessment Form

Applicant Information

Personal Information

Housing History

Legal Information

Income Information

Employment & Education

If employed, please provide the following:

Program Interest & Goals

Acknowledgement & Signature