KDG Pre-Screening Client Intake Form
Please complete all sections to help us assess your eligibility and support needs. All information is confidential.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Current Address
*
Emergency Contact Name
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Emergency Contact
*
Current Status
*
Stable housing
Homeless
Transitional housing
Shelter
Other
If not stable, how long have you been in your current situation?
Reason for seeking new housing
*
Lease ending
Unsafe environment
Cost
Transitioning from shelter
Other
Please explain your reason for seeking new housing
Have you rented before?
*
Yes
No
Previous landlord name & phone
Do you have any unpaid rent or balances owed?
*
Yes
No
Have you lived in a shared/group setting before?
*
Yes
No
If yes, please describe your experience in a shared/group setting
Employment Status
*
Employed
Unemployed
On Assistance (SSI/SSDI)
Retired
Income Source(s)
*
Monthly Income (USD)
*
Expected move-in date
-
Month
-
Day
Year
Date
Can you pay rent on time each month?
*
Yes
No
Sometimes
Do you have a representative payee?
*
Yes
No
If yes, payee name & contact information
Required Income Verification (select all that apply)
Pay stub (last 30 days)
SSI/SSDI award letter (current year)
Unemployment statement
Pension/retirement statement
Bank statement (last 30 days)
Do you prepare your own meals?
*
Yes
No
With Assistance
Can you manage your own medications without reminders?
*
Yes
No
With Assistance
Can you handle personal hygiene and self-care?
*
Yes
No
With Assistance
Can you use public transportation or arrange your own rides?
*
Yes
No
With Assistance
Can you manage your own schedule and appointments?
*
Yes
No
With Assistance
Can you communicate your needs to staff or others?
*
Yes
No
With Assistance
Can you handle basic household chores (cleaning, laundry)?
*
Yes
No
With Assistance
Can you make decisions about your daily routine independently?
*
Yes
No
With Assistance
Can you handle a minor emergency (call 911, contact staff) on your own?
*
Yes
No
With Assistance
If any item above is marked 'No' or 'With Assistance', please describe the support currently in place (details)
Do you have a documented disability?
*
Yes
No
If yes, what type of disability?
Are you currently receiving Medicaid Waiver services for personal care?
*
Yes
No
If yes, what type of waiver assistance do you receive?
CCC Plus (EDCD)
DD Waiver
Building Independence Waiver
Other
Waiver provider/agency name & contact
Are you currently receiving mental health services?
*
Yes
No
Provider name & contact
Do you have a case manager or support worker?
*
Yes
No
Case manager name & contact
Are you currently on medication?
*
Yes
No
Can you manage your medications independently?
*
Yes
No
Have you had a psychiatric hospitalization in the last 12 months?
*
Yes
No
If yes, please explain (psychiatric hospitalization)
Do you have a history of self-harm or harm to others?
*
Yes
No
If yes, please explain and describe current stability
Have you had issues with drug or alcohol use?
*
Yes
No
Are you currently in recovery?
*
Yes — Active recovery program
Yes — Independent sobriety
No
N/A
Are you willing to comply with a zero-tolerance substance policy?
*
Yes
No
Do you currently have any active collections or judgments?
*
Yes
No
If yes, please describe (collections or judgments)
Have you received public benefits (HUD, Section 8, TANF, etc.)?
*
Yes
No
Currently receiving
Do you have a bank account?
*
Yes — Checking
Yes — Savings
No — Prepaid card
No account
How do you typically pay bills? (Select all that apply)
Auto-pay
Online
Money order
Cash
Rep payee handles
Have you had a housing voucher (Section 8, HUD, etc.) in the past?
*
Yes — currently active
Yes — no longer active
No
Do you have any criminal convictions?
*
Yes
No
If yes, please specify the nature of the offense and date
Are you currently on probation or parole?
*
Yes
No
If yes, PO name & contact
Do you have any sex offender registration requirements?
*
Yes
No
Are you comfortable in a shared living environment?
*
Yes
No
Are you comfortable sharing a bedroom?
*
Yes
No
Do you smoke cigarettes or tobacco?
*
Yes
No
Do you have pets?
*
Yes
No
Do you have a vehicle?
*
Yes
No
Do you agree to the above rules and expectations?
*
Yes
No
Applicant Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: