This is what I need in my intake form- Hands 2 Heaven Living LLC
Client Intake & Screening Form
1. Basic Information
These questions help you identify and contact the applicant.
Full Name
Date of Birth
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Month
-
Day
Year
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Current City & State
Emergency Contact Name & Phone Number
Relationship to Emergency Contact
2. Current Housing Situation
This helps you understand their immediate need.
What is your current living situation?
Homeless
Staying with friends/family
Shelter
Temporary housing
Other
How long have you been without stable housing?
Are you currently receiving assistance from any programs or shelters?
Are you currently employed?
Full-time
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Part-time
Not employed
Receiving disability or assistance
Monthly income (if any)
3. Household Information
Important for your women/children housing plans.
Will you be living alone or with family members?
If with children, please list
Number of children
Ages
Do you currently have custody of your children?
4. Program Eligibility Questions
These help determine if they fit the Hands 2 Heaven mission.
What led you to seek housing through Hands 2 Heaven Living?
Which program are you applying for?
Independent living
Mothers with children housing
Senior housing
Reentry housing (transitioning from incarceration)
Mental health support housing
Are you currently working with a case manager or social worker?
If yes, please provide their name and organization.
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5. Background & Stability Screening
Important for safety and community environment.
Have you ever been convicted of a violent crime?
Yes
No
If yes, please explain.
Are you currently on probation or parole?
Are you required to register as a sex offender?
Have you lived in a structured housing program before?
6. Health & Support Needs
This helps you understand how to support residents.
Do you currently receive mental health services?
Do you take any prescribed medications?
Do you have any medical conditions we should be aware of?
Do you require assistance with daily living activities?
Are you currently participating in counseling, recovery, or treatment programs?
7. Program Commitment
This protects your housing community.
Are you willing to follow community guidelines and house rules?
Are you willing to participate in life-skills programs or community meetings?
Are you willing to maintain a clean and respectful living environment?
Are you willing to contribute toward program fees or rent if applicable?
8. Goals & Personal Development
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This aligns with your second chance mission.
What are your personal goals for the next 6-12 months?
What support do you hope to receive from Hands 2 Heaven Living?
Are you interested in:
Job placement resources
Financial literacy classes
Parenting support
Mental health resources
Life skills training
9. Additional Information
Is there anything else you would like us to know about your situation?
10. Agreement & Consent
Include a short statement such as:
I certify that the information provided is accurate to the best of my knowledge. I understand that submission of this form does not guarantee placement and that Hands 2 Heaven Living LLC may conduct additional screening prior to acceptance into the program.
I agree
Signature
Date
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Month
-
Day
Year
Date
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