S&G Revitalize Living - Shared Housing Program Intake Form
CONFIDENTIALITY NOTICE: All information provided will be kept confidential and used solely for eligibility and housing placement purposes.
1. Personal Information
Full Name:
First Name
Last Name
Date of Birth:
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Month
-
Day
Year
Date
Sex:
Phone Number:
Email Address:
example@example.com
Current Address:
City/State/ZIP:
Race:
2. Marital Status & Citizenship
Marital Status (circle one):
Single
Married
Divorced
Widowed
Citizenship Status:
3. Emergency Contact Information
Name:
Relationship:
Phone Number:
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Address:
4. Income Source & Assets
Primary Source of Income:
Monthly Income:
Other Sources of Income:
List any Assets (bank accounts, property, etc.):
5. Social Security Number
SSN:
6. Previous Housing History
Previous Address:
Length of Stay:
Reason for Leaving:
7. Health & Mental Illness Diagnoses
Are you ordered any medications?
If yes, please list:
Do you have any physical or mental health diagnoses? Yes / No
Yes
No
If yes, please specify:
Please list any medication you are currently taking:
8. Domestic Violence Information (if applicable)
Have you experienced domestic violence? Yes / No
Yes
No
2
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Do you have any violence charges/conviction? Yes/No
If yes, Please explain:
9. Required Documentation Checklist
Proof of Income
Birth Certificate
Driver's License or State ID
Social Security Card
10. Criminal Record (this does not disqualify you from the program.)
Please explain:
Are you currently on probation or parole?
If yes, please explain:
Are you registered as a sex offender?
If yes, please explain:
11. Certification & Signature
Our program is designated for individuals who are 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 24/7 in person 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: If you require medical or personal care services, they must be provided by a licensed outside agency, arranged and paid for separately, with directors approval.
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I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, belongings, and daily living tasks. I will not hold the program responsible for services outside the scope of independent living.
I certify that all information provided above is true and complete to the best of my knowledge. If I am selected for the program, I consent to fully comply with all program policies and house rules at all times.
Signature:
Date:
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Month
-
Day
Year
Date
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