Supportive Housing Client IntakeForm

Supportive Housing Client IntakeForm

Alliance Living Solutions - Participant Intake & Enrollment Application
Date of Intake

MonthDayYear
Date
🧾 Referral Agency/ Name of Referrer
Full Name

First NameLast Name
Date of Birth
Age
Social Security Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Gender
Emergency Name
Emergency Contact Phone Number
Relationship to Emergency Contact
CurrentLiving Situation
BriefSummary of Situation / Reason for Housing Need
Medical& Mental Health History (List Below)
Substance use history (if any):
LegalBackground - Are you currently on parole or probation? (ListPO Name/Phone Number)
Are you a registered sex offender?
Do you have a source of income?

Other
Monthly Income Amount (if any)
Any disabilities or accommodations needed?
If you have any disabilities please explain
Independent Living & Functionality Acknowledgment

Our program is designed for individuals who are high-functioning and capable of living independently. This is not a personal care home, nursing home, or 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
• Medication (unless managed by an outside provider)
• Mobility and transportation arrangements
• 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 yourActivities of Daily Living (ADLs) without assistance?
Do you currently have or need a home health careprovider or outside support service?
I understand and agree that this programprovides housing only. I will be responsible for my personal care, medicalneeds, and daily living tasks. I will not hold the program responsible forservices outside the scope of independent housing.
Signature
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
Participants Signature
Staff Name
Staff Signature
Should be Empty: