Independent Housing Client Intake Form

Independent Housing Client Intake Form

Please complete this form to help us understand your needs.
Participant Intake & Enrollment Application
Full Name

First NameLast NameSuffix
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Referral Agency

Case Manager Name

Company
PhoneEmailDate of Intake
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Living Situation

Other
Referral Source (if applicable)

Family/Friend
Please provide a brief summary of your situation and reason for a housing need.
Medical & Mental Health History (please list below)
Please include mental health diagnosis (if any)
Substance Use/Abuse History (if any)
If other, please provide details below.
Legal Background (please check if yes)
Please provide Probation/Parole Officers information (if applicable)
Income/Resource Information (please check if yes)
What is your source of income?
Housing Preference or Needs (please check if yes)
What is your monthly income?
What type of support or accommodations do you need?
Do you have any allergies?
Is there anything else you would like us to know?
Independent Living & Functionality Agreement

Our program is designed for individuals who are high-functioning and capable of living independently. This is NOT a personal care home, nursing home, group 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 activities
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 your Activities of Daily Living (ADLs) without assistance?
If no, please explain
Do you currently have or need a home health care provider or outside support service?
If yes, what's the agency name?
I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent living.
I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins.
I acknowledge that program participation is month-to-month and violating rules may result in a strike and/or immediate dismissal from the program.
Participant Initials
Date
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
Participant Signature
Date
Staff Name
Staff Signature
Date
Should be Empty: