Smart PDF Form

What Do You Hope to Gain from APL?*

Specific Resources Requested (Employment, Education, Etc.):*

Open to Weekly Case Management Check-Ins*

YesNo

Open to Workshops/Classes*

YesNo

What Motivates You Most to Succeed?*

Allergies (Food/Medication):*

Mobility or Safety Concerns:*

Preferred Hospital:*

Advance Care Plan / Healthcare POA*

YesNo

Details:*

DOCUMENTATION CHECKLIST

Verified Release Date:

Referral Source:

Participant Demonstrates Independent Living Readiness

YesNo

Understands Program Structure and Rules

YesNo

Staff Notes:

Participant Acknowledgment
I understand that AnchorPath Living is a structured independent-living program, not a
halfway house or treatment facility, and that continued participation depends on
compliance with all program rules and guidelines.

Participant Signature:*

Date:*

Date

Interviewer Signature:

Date:

Date

Confidentiality Notice: All information provided in this application will remain confidential and is used solely for determining eligibility, placement, and support within AnchorPath Living's housing program. Information will not be shared with outside parties without written consent, except as required by law or supervision conditions.

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ANCHORPATH LIVING – REENTRY INTAKE & TRANSITION APPLICATION

FOR OFFICE USE ONLY

GENERAL INFORMATION

EMPLOYMENT & INCOME

MEDICAL & BEHAVIORAL HEALTH

LEGAL & HOUSING HISTORY

REENTRY & TRANSITION PLANNING

RISK & BEHAVIOR INDICATORS

SUPPORT NETWORK & ACCOUNTABILITY

SUPPORT NEEDS & GOALS

LIFESTYLE & HABITS

PERSONAL HISTORY & STABILITY

SERVICE PREFERENCES

EMERGENCY PLANNING

STAFF USE ONLY – REENTRY READINESS ASSESSMENT

SIGNATURES