Dream Horizon Living Supportive Intake Form
We’re so glad you want to join our program. This intake form is to make sure you’re a great fit for our community. If you have any additional questions please contact our office. You’re one step closer to joining Dream Horizon Living.
Participant Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Last 4 numbers of Social Security Number
Sex at Birth
*
Male
Female
Phone Number
Please enter a valid phone number.
Email
example@example.com
Brief Summary of Situation / Reason for Housing Need
Emergency Contact Information
Emergency Contact Name
First Name
Last Name/ Last Name Initial
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Participant:
Current Living Situation
Please select below:
*
Homeless
Couchsurfing / Stayingwith others
Transitional Housing
Jail/Prison Release
Hospital / Rehab
Other
If you clicked "Other" for the question above, please specify below:
Referral Source (If Applicable)
Self
Agency
Parole/Probation
Hospital or Treatment Center•
Family/Friend
Medical & Mental Health History
Do you have any mental health history?
*
Please Select
Yes
No
Please list any mental health diagnosis along with medication. (if any)
If none, please type "None".
Do you have any history with substance abuse?
*
Please Select
Yes
No
If yes, select below:
Please Select
Drugs
Alcohol
Both
None
Legal Background
Are you currently on parole or probation? If yes, please list details below.
*
Please Select
Yes
No
This does not disqualify you.
PO Name
First Name
Last Name
PO Phone Number
Please enter a valid phone number.
Are you a registered sex offender?
*
Please Select
Yes
No
Income Information
Do you have a source of income?
*
Please Select
Yes
No
What is your source of income?
*
SSI
SSDI
Employment
Other
None
Monthly Income Amount (if any)
*
If none, type "0"
Housing Preferences or Needs
Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?
Please Select
Yes
No
Do you currently have or need a home health care provider or outside support service?
Please Select
Yes
No
Any disabilities or accommodations needed?
Yes
No
If you answered "yes" above, please explain:
Preferred Room Type:
Shared
Private (if available)
Desired Move in Date
-
Month
-
Day
Year
Date
Independent Living & FunctionalityAcknowledgment
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.
Program Agreement Preview
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 housing. 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 violating rules may result in a strike or dismissal from the program.
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.
Full Name/ Signature
First Name
Last Name
Submit
Should be Empty: