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
SelfCase ManagerProgramOther
Personal Information

Tell us about yourself.
Age*
MaleFemaleOther
YesNo
If yes, expected due date

MonthDayYear
Date
YesNo
YesNo
SingleMarriedDivorcedSeparatedWidowed
YesNo
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
Residential Care / TreatmentBoard & CareHospitalPrison / JailHomeless ShelterHomeless (street / vehicle / encampment)Other
Reason for leaving your previous/current housing
Legal Information

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

Please indicate your sources of income.
NonePublic AssistanceSSISSDIRetirementWelfareAlimony / Child SupportOther (specify)
Employment & Education

Tell us about your employment and education background.
Highest Level of Education Completed
YesNo
Employed Full-TimeEmployed Part-TimeUnemployed (actively seeking employment)Attending school or training programVolunteer / Non-competitive workOther (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*

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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