• Colorful Welcoming House with a heart at the center

    INTAKE FORM

    Please complete all fields before submitting.

  • Client Information

  • Format: (000) 000-0000.
  • Best Time to Reach You:
  • 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?
  • Which county do you prefer?

  • 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

  • Do you currently or have you ever used any illegal substances?
  • 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, the company is 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

  • Are you currently employed?*
  • Pay Frequency:
  • Next Pay Date:
     - -

  • Identification & Documents

  • Do you have identification?*

  • Move-In Timing

  • When are you planning to move?
  • *

  • Agreement & Certification

  • Please note, there is a $300 one-time move-in fee due to hold your requested room.

  • Rent is due the day of move-in and will be prorated if you move in after the 1st of the month.
  • 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.

  • *
  • Date:
     - -
  • Should be Empty: