• Colorful Welcoming House with a heart at the center

    INTAKE FORM

    Currently serving Illinois (Macon County) and surrounding areas

  • Client Information

    (Please complete all fields before submitting.)
  • Format: (000) 000-0000.
  • Best Time to Reach You:
  • Who are you applying for?
  • Gender:
  • Date of Birth:
     - -

  • Demographic Information

  • Please indicate your race/ethnicity (select all that apply):
  • Race/Ethnicity
  • Do you identify as a member of the LGBTQ+ community?

  • Emergency Contact

  • Format: (000) 000-0000.

  • Criminal & Legal History

  • Have you ever been convicted of a crime? ( Answering yes does NOT disqualify you)*
  • Do you have any criminal convictions pending?*

  • Current or Prior Living Circumstances

  • Are you transitioning from any of the following situations?

  • Current Support Services

  • Do you currently have a case manager, social worker, or program contact?*

  • Substance Use & Health

  • Any current or previous alcohol/substance use?*
  • Any known allergies?*
  • Do you have any mental illnesses?*
  • If so, has this been diagnosed by a physician?
  • Are you currently prescribed any medications?*
  • Do you self-administer?

  • (Please note, we are not a medical facility and cannot administer medication.)

  • Would you benefit from medication reminders?
  • (A staff member can remind you when it's time to take your medication.)

  • Accessibility & Physical Needs

  • Do you have any physical limitations or accessibility needs?*

  • Housing Preference

  • Which are you applying for?*

  • Employment & Income

  • If any, how many sources of income do you have?*
  • Are you currently employed?*
  • Pay Frequency:
  • Next Pay Date:
     - -
  • Next Pay Date:
     - -
  • Do you receive SNAP/EBT benefits?*

  • Identification & Documents

  • Do you have valid proof of identification?*
  • When are you planning to move?*
  • Do you have (or can you obtain) proof of income?*

  • Move-In Readiness

  • Do you anticipate having the funds or assistance needed to complete your move-in when a room becomes available?*
  • How will you cover your move-in costs?*

  • Agreement & Certification

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Rent is due the day of move-in. Pricing varies based on room availability and size.

  • Please note, there is a non-refundable $300 one-time move-in fee due upon move-in.

  • Do you understand and agree?*
  • By agreeing below, I certify that the information provided is true and complete to the best of my knowledge. I understand that Sweet Living House is a drug- and alcohol-free environment and that all residents must follow the program rules and policies to remain in good standing.*
  • Should be Empty: